WELCOME! PASRR Road Show Spring 2019 1 2019 Ascend, A MAXIMUS Company. All rights reserved. Who We Are + Headquartered in Reston, Virginia; Based in Franklin, Tennessee 250 Employees across the county Network of 500+ independent contractor clinicians and physicians + Services Provided Conflict-free clinical assessment services Customized data systems and clinical algorithms Intense focus on clinical quality produce highly defensible outcomes 2 2019 Ascend, A MAXIMUS Company. All rights reserved. 1
Training Partners and Notecards 3 2019 Ascend, A MAXIMUS Company. All rights reserved. Morning Agenda Time Topic 9:00 9:10 AM Introductions 9:10 10:00 AM PASRR & Compliance 10:00 10:15 AM Managed Care Organizations & Data Sharing 10:15 10:30 AM Break 10:30 11:00 AM Table Top Exercise 11:00 11:45 PM Status Change / Resident Review 11:45 12:00 PM Q & A 4 2019 Ascend, A MAXIMUS Company. All rights reserved. 2
Afternoon Agenda Time Topic 1:00 1:45 Guest Speaker Iowa Department of Inspections and Appeals 1:45-2:00 Break 2:00 2:45 Nursing Facility for persons with Mental Illness (NFMI) Level of Care and Compliance Issues 2:45 3:45 PASRR, Dependent Adult Abuse; the value and importance of collaboration 3:45 4:00 Q & A 5 2019 Ascend, A MAXIMUS Company. All rights reserved. BRAD GOODIN, MDiv IOWA & NEBRASKA PASRR PROGRAM MANAGER Brad joined Ascend, A MAXIMUS Company in 2016. He started as a Quality Coordinator reviewing PASRR Level II assessments. He was quickly promoted and now serves as the manager of the Iowa PASRR program at Ascend. Brad has over 10 years in supervisory roles and extensive knowledge of IDD, Mental Health, and Medicaid service delivery systems. Brad s leadership experiences include serving as Executive Director of two provider agencies, Director of Operations, Lead Investigator for the State of Tennessee, and Senior Management at a social work agency. 6 2019 Ascend, A MAXIMUS Company. All rights reserved. 3
Becky Laney, MA Quality Manager, Quality Department Becky joined Ascend, A MAXIMUS Company in March 2016 as a Quality Coordinator reviewing Level II PASRR Assessments in Iowa. Becky also headed the revision of Nursing Facility for persons with Mental Illness (NFMI) Summary of Findings to help address the needs of this population. Becky came to Ascend with over six years of experience in assessing and writing detailed treatment plans so that individuals can receive the best care possible. Becky came to Ascend with over ten years of experience in assessing and writing treatment plans so that individuals with disabilities receive the best care possible. Most recently, Becky was promoted to Quality Manager of the Quality Department in 2019, where she monitors and develops quality tools, plans, processes, and quality implementation strategies for contracts within Ascend. 7 2019 Ascend, A MAXIMUS Company. All rights reserved. Lila Starr, LBSW IA DHS, Division of Mental Health & Disability Services Lila has worked for the Iowa DHS for thirty+ years and has been a mental health specialist in the Division of Mental Health and Disability Services (MHDS) since 1999. She has had a variety of responsibilities; Adult & Older Adult Mental Health Specialist, Olmstead Coordinator, PATH Coordinator, Disaster Mental Health Coordinator. She has managed a variety of contracts and projects in areas including adults and older adults with mental illness, as well as other disabilities. Lila created and managed the Iowa Peer Support Training Academy 2005 2014. She has served as the MH Specialist for older adult mental health 1999 and as Iowa s designee, Chair, member of the Executive Committee, and Secretary to the Older Persons Division of the National Association of State Mental Health Program Directors since 1999. Lila is the co-founder and creator of the Iowa Coalition on Mental Health and Aging, which launched in 2005 and is part of the National Coalition on MH and Aging. Lila is a member of the Board of Directors of the National Association of PASRR Professionals (NAPP), and currently serves as Secretary and Governance Committee Chair. Since November 2011, Lila has been the program manager for the Preadmission Screening and Resident Review program (PASRR). She administers the contract with Ascend, a Maximus Company, to conduct PASRR in Iowa. She loves to consult with PASRR providers! 8 2019 Ascend, A MAXIMUS Company. All rights reserved. 4
Mindla White, Iowa Department of Inspections and Appeals, Health Facilities Division Administrator Mindla (Mindy) White has been the Medicare/Medicaid Bureau Chief since December 2005. Current responsibilities include oversight for long term care facilities in Northwest and Southeast Iowa. Ms. White also oversees the enforcement program for both state and federal sanctions. Ms. White joined the Health Facilities Division in January 1998 as a Health Facilities Surveyor for long term care facilities. Ms. White was also compliance officer and had the responsibility of issuing state and federal enforcement actions from December 1999 to December 2005 until her new assignment as Bureau Chief. Ms. White received her associate degree nursing license in 1993 from Southwest Wisconsin Technical College, Fennimore WI. In 2003, she received a Bachelor of Science Degree in Nursing from Mercy College in Des, Moines, IA. 9 2019 Ascend, A MAXIMUS Company. All rights reserved. Learning Objectives of Spring 2019 PASRR Road Show Develop a deeper understanding of PASRR and compliance issues Learn to identify at least five ways to comply with PASRR Discuss the collaboration between PASRR, DHS, APS, MCOs, and DIA to enhance better outcomes for individuals Enhance understanding of Status Change/Resident Review Improve understanding of NFMI level of care & when it is best identified and utilized 10 2019 Ascend, A MAXIMUS Company. All rights reserved. 5
Acronyms APS - Adult Protective Services CFEU Centralized-Facility Eligibility Unit CMS Centers for Medicaid and Medicare (Federal home agency for Medicaid & PASRR) DA - Dependent Adult DD Developmental Disability DIA Iowa Department of Inspections and Appeals Health Facilities Division is primary for PASRR HIPAA Health Information Portability and Accountability Act (privacy of PHI) ID Intellectual Disability (the term mental retardation, is no longer to be used) IME Iowa Medicaid Enterprise, a Division of IA Department of Human Services NF Nursing Facility NFMI Nursing Facility for persons with Mental Illness / Also known historically in Iowa as an ICF-PMI (intermediate care facility for persons with mental illness / A unique level of care for individuals with SMI and significant behavioral management challenges PASRR Preadmission Screening and Resident Review PHI Personal Health Information RC Related Condition(s), many kinds of developmental and/or physical conditions covered by PASRR SMI Serious Mental Illness, defined differently at Federal, State, and Local levels, and by program SNF Skilled Nursing Facility 11 2019 Ascend, A MAXIMUS Company. All rights reserved. Use of Person First and Aging Appropriate Language Person First Language popularized in the late 90 s and 2000 s within the disability community, the concept of speaking of the person ahead of the disability thus highlighting the personhood of the individual. We will use such language in PASRR and in this presentation. Examples: Person with Mental Illness Person with physical disability Person who uses a wheel chair for mobility Aging Appropriate Language promoted within the community of professionals who work with older adults, use of the term Older Adults, rather than elderly Some programs put the starting place for older adult at the age of 60, Dept. on Aging Some federal and state programs put the starting place for older adults at age 65, Medicaid In Person First and Aging Appropriate language, we do not use of the word the in front of any broad descriptors of people The homeless The Elderly The Disabled 12 2019 Ascend, A MAXIMUS Company. All rights reserved. 6
Structure & Purpose of PASRR (What) Preadmission Screening & Resident Review Administered by Centers for Medicare and Medicaid Services (CMS) Created in 1987 Anyone applying for admission to any (Medicaid-certified) NF screened for PASRR Conditions : Serious Mental Illness (SMI), Intellectual/Developmental Disability (ID/DD), or Related Condition (RC) Known or suspected PASRR condition = evaluation (LII PASRR) To ensure NF is most appropriate placement To ensure receipt of needed services Level I is a screening to identify anyone with a Suspected or Known PASRR Condition Level I outcomes are Level I Negative, a Categorical / Exemption from LII, or Refer for full Level II. Level I Exemption and Categorical Outcomes EQUALS someone with a PASRR Level II condition Level II is a full evaluation of an individual with a suspected or known PASRR Level II condition 13 2019 Ascend, A MAXIMUS Company. All rights reserved. 1 Does the individual have a PASRR condition? Four Questions of PASRR 2 3 4 What is the most appropriate placement for this individual? (acute enough/too acute) Might this individual be a candidate for transition to the community? What supports or services would be necessary to return to his/her community? What unique disability supports and services does this individual need while a resident of a NF to ensure safety, health, and well-being? 14 2019 Ascend, A MAXIMUS Company. All rights reserved. 7
1 Does the individual have a PASRR condition? Identify need for a new PASRR and encourage submission. Reviewer s Role In the Four Questions of PASRR 2 What is the most appropriate placement for this individual? (acute enough/too acute) Encourage early intervention by members of the individual s Circle of Support in any hospitalization and present alternatives to nursing facility care. Preventing premature placement in nursing facilities through coordinated care management, services that support community tenure, and promotion of recovery. 15 2019 Ascend, A MAXIMUS Company. All rights reserved. Reviewer s Role In the Four Questions of PASRR 3 4 Might this individual be a candidate for transition to the community? (What supports or services would be necessary to return to his/her community?) Monitor PASRR Compliant care planning and Service Delivery and NF s active discharge planning. Reviewer s can partner early to help the NF in achieving successful discharge. What unique disability supports and services does this individual need while a resident of a NF to ensure safety, health, and well-being? Understand the Service Matters process and continue with care plan / service monitoring beyond the Service Matters Review. 16 2019 Ascend, A MAXIMUS Company. All rights reserved. 8
United States Supreme Court Case Olmstead v EW and LC June 22, 1999 Photo courtesy Jeffrey Macmillan for US News &World Report 17 2019 Ascend, A MAXIMUS Company. All rights reserved. 17 The Olmstead Supreme Court Decision- June 22, 1999 US Supreme Court ruled that Unjustified Segregation constitutes discrimination under the Americans with Disabilities Act Public entities (States and Local Governments) must provide communitybased services when: + Determined Appropriate to meet a persons needs + Persons do not oppose community-based treatment + Community-based services can be reasonably accommodated (financed) Diversion from NF Placement and Transition from NF Placement must be reviewed and achieved whenever possible 18 2019 Ascend, A MAXIMUS Company. All rights reserved. 9
PASRR provides perhaps the most powerful lever in all of Medicaid law to encourage diversion and transition. PASRR Technical Assistance Center s (PTAC)September 2013 Report to CMS Review of State PASRR Policies and Procedures. 19 2019 Ascend, A MAXIMUS Company. All rights reserved. Overview of PASRR Compliance Of Level I / Level II / Service Matters & Path Tracker Plus 20 2019 Ascend, A MAXIMUS Company. All rights reserved. 10
Resident Review w/ Relevant Status Change Nursing Facility Level I Disability Screen Level II In-Depth Evaluation Determination & Notification = Summary of Findings Other Appropriate Placement 21 Who receives a Level I? EVERYONE Entering/residing in a Medicaid-certified NF + Regardless of payer source + Regardless of diagnoses + Regardless of current location 22 11
Iowa Monitoring of PASRR Pre-Admission & Status Change Compliance + Failure to complete a PASRR prior to admission to the nursing facility. + Failure to secure an approved (new) PASRR prior to a expiration of a categorical and / or other short term PASRR Leve II approval + Failure to submit a new Level I when the individual meets the criteria for a significant change in status, (MDS 3.0) + We frequently repeat Webinars on Status Change/Resident Review. The most recent was on March 5, 2019 at 2:00 PM and covered the topic of Status Changes in depth + Registration for Webinars is always on Iowa PASRR website: https://www.ascendami.com/pasrr/application/iowadefault.aspx, but announcements are also sent out to the full distribution list of our providers 23 2019 Ascend, A MAXIMUS Company. All rights reserved. Common Level II Summary of Findings Compliance Issues Failure to ensure the PASRR remains in the active chart. Failure to ensure that the PASRR is a clinically accurate representation of the individual. + Status Changes must be submitted when appropriate Failure to review PASRR prior to placement to ensure that the facility has the capacity to deliver identified services.* + This is still a surprisingly frequent problem + *This is most evident in NF s that accept individuals with the NFMI/OR outcomes. 24 2019 Ascend, A MAXIMUS Company. All rights reserved. 12
120.00% Pre Admission Compliance 2016 2018 100.00% 94.39% 95.65% 94.23% 80.00% 60.00% Compliant Non-compliant 40.00% 20.00% 0.00% 5.61% 4.35% 5.77% 2016 2017 2018 25 2019 Ascend, A MAXIMUS Company. All rights reserved. Four Goals of ServiceMatters Measure and report care plan compliance and service delivery for ALL PASRR identified services Monitor delivery of PASRR identified services, particularly Specialized Services Measure and report on gaps in availability of PASRR identified services and/or providers in communities Evaluate changing needs of each person 26 2019 Ascend, A MAXIMUS Company. All rights reserved. 13
` PASRR Care Planning Components Name the provider of PASRR identified services Start date of services Anticipated frequency of services Anticipated duration of services Specialized Services Rehabilitative Services Community Placement Supports* 27 2019 Ascend, A MAXIMUS Company. All rights reserved. 2018 86.76% 13.24% Service Matters Compliance 2016-2018 2017 86.24% 13.76% Compliant Non-compliant 2016 80.89% 19.11% 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 28 14
Iowa Monitoring of Care Plan / Service Delivery Compliance + Failure to complete a PASRR Compliant Care Plan, with all four required elements for EACH PASRR identified service + Failure to arrange for TIMELY delivery of all PASRR identified services, particularly Specialized Services immediately upon placement, which can lead to decline in quality of care, increase risk for hospitalization or other higher LOC, and failure to achieve goals related to discharge to lower LOC + Failure to obtain and provide specific evidence of service delivery / coordination of PASRR identified Specialized Services + Failure to actively care plan for Community Placement Supports when appropriate and engage in proactive discharge planning for individuals with high potential for discharge into the community + Failure to reach out and engage with the MCO, options counselors, case managers, legal guardian, family/support network, and other service providers to support discharge planning. 29 2019 Ascend, A MAXIMUS Company. All rights reserved. Using PathTracker 30 2019 Ascend, A MAXIMUS Company. All rights reserved. 15
Turnaround Times in Days for PathTracker Plus 24 22 21 20 18 18 16 14 12 10 12 7 8 6 4 2 0 2016 to 2017 2016 to 2017 2018 2018 Admission Notice Discharge Notice Admission Notice Discharge Notice 31 2019 Ascend, A MAXIMUS Company. All rights reserved. Enhanced access to PASRR records Print PASRR outcomes/forms for resident charts Links to Payment Became Mandatory 2/1/2016 Submit Status Change Level I screen Admissions, Discharges, Transfers 32 16
Admission Notice 33 2019 Ascend, A MAXIMUS Company. All rights reserved. Admission Notice, cont. 34 2019 Ascend, A MAXIMUS Company. All rights reserved. 17
Discharge/Transfer Notice, cont. 35 2019 Ascend, A MAXIMUS Company. All rights reserved. Case Activity Report Form That Iowa DHS CFEU Workers Use 36 2019 Ascend, A MAXIMUS Company. All rights reserved. 18
Quick Tip Sheets for PathTracker Plus 37 2019 Ascend, A MAXIMUS Company. All rights reserved. Important Points about PathTracker Plus You MUST fill out the admission notice (within 2 days) This STARTS payment Complete discharge notice when person permanently leaves or hospitalized for 11 days or more (within 2 days) This STOPS payment Do not accept a resident through the review queue until they are in your facility 38 2019 Ascend, A MAXIMUS Company. All rights reserved. 19
IME Best Practices for PathTracker Plus This Information is what is presented to Nursing Facilities Others do not use PathTracker Plus + Complete an Admission Notice, Discharge Notice or Transfer timely (within 2 days) + Never admit someone using PathTracker in order to complete a Level I PASRR Screening + Use the correct Admission Date + Use accurate provider/npi numbers + If you don t admit the person, don t submit an admission notice + No Discharge notice is needed if the person goes to the hospital for less than 10 days + Never submit a paper Case Activity Report, even if requested to do so by DHS Income Maintenance (CFEU) staff, instead make all entries for Admissions, Transfers, and Discharges, as well as changes in pay source in PathTracker Plus + If you are admitting someone to your facility with a NFMI/OR outcome you must indicate NFMI as the level of care on the admission notice 39 2019 Ascend, A MAXIMUS Company. All rights reserved. Who Uses PathTracker Plus and Who does not use PathTracker Plus Those that do use PathTracker Plus: + Nursing Facilities + Nursing Facilities for Individuals with Mental Illness (NFMI) Those that do not use PathTracker Plus: + Hospitals + Hospitals with Swing Beds* + PACE Providers* + Hospice Providers* *These entities will need to submit Paper versions of the Case Activity Report (CAR) 40 2019 Ascend, A MAXIMUS Company. All rights reserved. 20
What do MCO s and other Reviewers Get 41 2019 Ascend, A MAXIMUS Company. All rights reserved. MCO Monthly Data Transfer File File Contains the following information MCO Key Client ID Level I ID Assessment ID Level I Review Date = Level I Complete Date Level I Outcome Level II Review Date = Level II Complete Date Level II Outcome Length of stay on short term approval of a Level II List of Services Identified in the Level II State ID First Name Last Name Social Security Number PathTracker Admission Date Facility Provider number Date PathTracker Notice is completed Contact name of person completing the PathTracker Notice Contact Phone number PathTracker Discharge Date Facility Name Facility Address 42 2019 Ascend, A MAXIMUS Company. All rights reserved. 21
Guidance to Reviewers on PASRR data + Review the Level I complete date. This equals the PASRR completion date if the person doesn t require a Level II. + Review the Level II complete date. This equals the PASRR completion date. + Verify ALL Services identified by PASRR are included in nursing facility s Care Plan and they are written in a PASRR compliant fashion. + Verify that the PathTracker Admission notice has been completed TIMELY. This is done by comparing the Admission date to that of the PathTracker Admission Notice date. The Admission Notice should be completed with 2 business days of actual admission. + Verify Preadmission compliance by confirming that the admission occurred on or after the day of the PASRR completion date. 43 2019 Ascend, A MAXIMUS Company. All rights reserved. Guidance to Reviewers on PASRR data Continued + Verify that the NF has made TIMELY submission of new PASRRs for any person with a prior short term approval (within 10 days of expiration). + Verify that discharge planning is being actively undertaken and all Community Placement Supports identified by PASRR are documented in the NF Care Plan for anyone with a short term approval or anyone who has expressed a desire for discharge to a lower level of care (in MDS or other ways). + Verify evidence of actual service delivery of all PASRR identified services. + Ensure that the NF has contacted MCO care managers for assistance with service coordination of any/all identified PASRR services. + For those individuals with high potential for discharge to a lower LOC, communication between NF and MCO and /or Options Counselor is imperative, for monitoring of progress and implementation of Community Placement Supports in particular. 44 2019 Ascend, A MAXIMUS Company. All rights reserved. 22
TABLE ACTIVITY 45 2019 Ascend, A MAXIMUS Company. All rights reserved. Compliance Example Number 1: CID 146727 Individual had a 60 Day Categorical Approval on 8-8-18 with an expiration of 10-7-18. (Categorical = PASRR LII condition). In a categorical determination, services are not identified, which can often delay the implementation of services that might facilitate a better outcome, and the NFs often do very little to facilitate discharge by the end of the categorical period. A new Level I screening was submitted on 10-8-18 a day after the prior PASRR Expired. The PASRR was referred for Level II on 10-8-18, and the Level II was completed on 10-14-18. This resulted in 6 days of PASRR Non-Compliance. The Level II dated on 10-14-18 was approved for 180 days with an expiration of 4-12-19. The facility was required to complete a PASRR compliant Care Plan within 21 days of 10-14-18 and a Service Matters review was triggered on 11-14-18. The facility failed to complete the initial Service Matters Review. This results in three months of PASRR Non-Compliance with regards to Service Matters and Discharge Planning. A second Service Matters Review was generated and completed on 12-21-18, which revealed no active discharge planning, a PASRR non-compliant care plan and a lack of supporting documentation/evidence of specialized services being provided. This results in 153 days of PASRR Non-Compliance and an individual with high potential for discharge in August may now start looking like a person who needs long term placement. The facility remains Non-Compliant with PASRR until such time as they begin to deliver all PASRR identified services and can document PASRR compliant care planning. 46 2019 Ascend, A MAXIMUS Company. All rights reserved. 23
Compliance Example Number 2: CID 188281 The individual received a short term PASRR approval on 7-10-18 of a 120 days with an expiration of 11-7-18, and was placed at the NF on 7-23-18. The facility completed zero discharge planning and failed to arrange for PASRR identified services, thus creating 107 days of PASRR Non-Compliance by the time the next PASRR is submitted. A new Level I was submitted on 11-5-18 and a Level II was completed on 11-7-18 with an outcome of a Level of Care Denial. The facility had met the physical goals regarding rehabilitation and the individual no longer met LOC for NF. Two full Service Matters reviews were conducted of the 7-10-18 PASRR with an outcome of Non-compliance with PASRR since date of placement on both Service Matters reviews. The individual submitted an appeal on 12-6-18 appealing the Level of Care Denial on 11-7-18. The facility did not begin discharge planning, but after consultation with Ascend and DHS, submitted a new Level I screening on 12-19-18. The new PASRR was completed on 1-4-19 and the nursing facility offered no evidence of any discharge planning in conjunction with this submission. Identified Psychiatric services have been minimal, and other required specialized services of individual therapy didn t begin until 12-4-18. This gentleman s entire stay in the NF has been out of compliance, resulting in 169 days of PASRR Non- Compliance as of 1-8-19. Another very short term approval of 90 days was approved on 1-4-19 due to new information that showed he minimally met LOC 47 2019 Ascend, A MAXIMUS Company. All rights reserved. Compliance Example Number 3: CID 98739 Nursing facility submitted a Level I on 3-27-18 and a Level II PASRR was completed on 4-3-18. Nursing facility did not complete an admission notice in PathTracker. The PASRR dated 4-3-18 generated a ServiceMatters review on 5-18-18. Ascend was able to do some detective work to determine the individual was placed in this nursing facility. Attempts were made on numerous occasions to contact the nursing facility to request that they submit a PathTracker admission notice, and the nursing facility chose not to submit an admission notice. This resulted in the ServiceMatters review being canceled. This case presents significant challenges as we have been unable to determine whether service delivery or compliant care planning has been happening, but it seems unlikely. Potentially, if the individual is still at the nursing facility, they have created 280 days of PASRR Non-Compliance as of 1-8-19. 48 2019 Ascend, A MAXIMUS Company. All rights reserved. 24
Iowa PASRR Compliance 1. Failure to complete a PASRR prior to admission to the nursing facility. 2. Failure to secure an approved (new) PASRR prior to a expiration of a categorical and / or other short term PASRR approval. 3. Failure to submit a new Level I screening when the individual meets the criteria for a significant change in status. 4. Failure to ensure the PASRR remains in the active chart. 5. Failure to ensure that the PASRR is a clinically accurate representation of the individual. 6. Failure to review PASRR prior to placement to ensure that the facility has the capacity to deliver identified services. 49 2019 Ascend, A MAXIMUS Company. All rights reserved. Iowa PASRR Compliance Continued 7. Failure to complete a PASRR Compliant Care Plan, with all four required elements. 8. Failure to provide evidence of service delivery / coordination of PASRR identified Specialized Services. 9. Failure to actively care plan and conduct discharge planning for individuals with high potential for discharge into the community. 10. If the facility fails to reach out to the MCO, options counselors, case managers and other service providers that support discharge planning is a factor that contributes to non-compliance. Complete an Admission Notice, Discharge Notice or Transfer timely. 11. Do not admit someone into PathTracker in order to complete a Level I PASRR Screening. 12. Use the correct Admission Date. 13. Use accurate provider/npi numbers 14. If you don t admit the person, don t submit an admission notice. 15. No Discharge notice is needed if the person goes to the hospital for less than 10 days 16. Nursing facilities should not complete a paper version of the Change Activity Report (CAR) 50 2019 Ascend, A MAXIMUS Company. All rights reserved. 25
BREAK TIME 51 2019 Ascend, A MAXIMUS Company. All rights reserved. Pre-Admission Screening and Resident Review (PASRR) Significant Change in Status (Resident Review)Considerations 52 2019 Ascend, A MAXIMUS Company. All rights reserved. 26
Purpose of Presentation To give context to the Pre-Admission Screening and Resident Review (PASRR) approach used in Iowa, with emphasis on Resident Review (Significant Change in Status) Evaluations To provide an opportunity for discussion and collaboration around the approach and guidance for Resident Reviews/Status Change 53 2019 Ascend, A MAXIMUS Company. All rights reserved. Before We Begin Rosa s Law (PL 111-256 replaces in law the term mental retardation with the term intellectual disabilities. Though those changes have not been made in their entirety in federal code, federal language is changed in this presentation in accordance with Rosa s Law. Prior Significant Change in Status training information is located here: www.ascendami.com/ami/portals/1/ime-informational-letter1939-mc- FFS.pdf?ZnBlNWhrWHNJYTR4ZE1LVnF1YWpSRGE5cUx5V2c1cnRRc0ZLRFR ZTStHRnVpckRpTkpFRXYyWjlZa1M4Z2hWcy83TDBxZ3dGbWR1UDFkVmRPTl c2nfe9pq2 54 2019 Ascend, A MAXIMUS Company. All rights reserved. 27
Pre-Admission Screening and Resident Review (PASRR) Regulatory Intent: To evaluate applicants and residents to Medicaid certified nursing facilities who have known or suspected serious mental illness or Intellectual/Developmental disability to identify: The most appropriate placement Any needed disability related services and supports 55 2019 Ascend, A MAXIMUS Company. All rights reserved. Federal Compliance (Accuracy--don t under-refer) Fiscal Responsibility (Efficiency--don t over-refer) Understand clinical symptoms that suggest a serious disability Use sensitive PASRR State Goals approaches Balance Accuracy and Efficiency 56 2019 Ascend, A MAXIMUS Company. All rights reserved. 28
Who should be referred? Federal Changes to the PASRR Mental Illness Definition 1987: + Any mental illness + Any psychotropic + A primary or secondary diagnosis of a mental disorder 1990: Impact of definition changes 1987 1990 1992 + A serious mental illness (efforts to narrow) that is not a primary dementia + A psychotropic that may mask a mental illness + Instructions for CMS to consult NIMH 1992: + Borrowed NIMH Serious and Persistent Mental Illness (SPMI) definition to define Serious Mental Illness + Diagnosis, Duration, Disability (Next slide) + Must evaluate known or suspected serious mental illness 57 2019 Ascend, A MAXIMUS Company. All rights reserved. Serious Mental Illness ( 483.102) The following are indicators of a serious mental illness. When those indicators are known or suspected, the person requires a PASRR Level II evaluation Diagnosis any mental disorder that may lead to a chronic disability; But not a primary diagnosis of dementia Disability Results in functional limitations in major life activities (past 6 months) e.g., difficulty interacting, communicating, sustaining attention, adapting to change, etc.) Duration Within the past 2 years received intensive treatment or experienced a significant disruption (e.g., psychiatric symptoms exacerbated) 58 2019 Ascend, A MAXIMUS Company. All rights reserved. 29
Federal Language regarding Diagnosis: mental disorder that may lead to a chronic disability; but not a primary diagnosis of dementia Dementia + Mental Health Condition If the both a dementia and a mental health condition are present, the Level I process will determine whether a Level II is needed depending on which is primary Mental illness is primary if it is likely to be the focus of treatment now or in the future Unclear whether symptoms are dementia or mental illness Some dementia behaviors look like other mental illness (psychosis, depression, etc.). The Level I process will determine if a Level II is needed 59 2019 Ascend, A MAXIMUS Company. All rights reserved. Methods states use to decide who has SMI and who should get referred to PASRR Level II 60 2019 Ascend, A MAXIMUS Company. All rights reserved. 30
Provider Decides + Highest risk + Effectiveness depends on provider insights about disability + High provider disincentive to accurately report disability + Fraught with conflict of interest + Until recent years, this was the most common approach 61 2019 Ascend, A MAXIMUS Company. All rights reserved. State Decides + Effectiveness depends on the comprehensiveness of the tool and the clinical skills of the state decision maker + Typically short tools enable providers to limit information reported about people with disability reinforces disincentive to report accurately + Fraught with conflict of interest + Increasingly common approach 62 2019 Ascend, A MAXIMUS Company. All rights reserved. 31
State Designated, Trained Clinician Decides + Addressed by CMS as a Level I.5 or a clinical decision to balance efficiency and accuracy + Matching a more robust tool to a more clinically trained disability expert is critical to achieve the efficiency and accuracy balance + Used now in about 1/3 of the states 63 2019 Ascend, A MAXIMUS Company. All rights reserved. CMS PASRR Self Assessment (2008) acknowledges: + Weakness of processes that permit providers to decide if a Level II is needed + Strength of Iowa s process of using trained clinicians to balance efficiency and accuracy 64 2019 Ascend, A MAXIMUS Company. All rights reserved. 32
MDS 3.0 Guidelines for Status 65 2019 Ascend, A MAXIMUS Company. All rights reserved. The following addresses the relationship between MDS 3.0 guidelines for Significant Change in Status and PASRR Level I and II https://downloads.cms.gov/files/mds-30-rai-manual-v115-october-2017.pdf 66 2019 Ascend, A MAXIMUS Company. All rights reserved. 33
MDS 3.0 identifies two types of Significant Change in Status: 1) Significant Change in Status Assessment (SCSA) 2) PASRR Significant Change in Status 67 2019 Ascend, A MAXIMUS Company. All rights reserved. MDS 3.0 identifies two types of Significant Change in Status: 1. Significant Change in Status Assessment (SCSA) 2. PASRR Significant Change in Status SCSA (A0310A=04) MDS 3.0 language says that a nursing home must update their MDS assessment in response to a significant change: + A comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either improvement or decline. + A significant change is a decline or improvement in a resident s status that: + Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only); + Impacts more than one area of the resident s health status; and + Requires interdisciplinary review and/or revision of the care plan. & Guidelines for when a PASRR Level II is needed MDS 3.0 language says that sometimes those assessments will trigger a PASRR Level II + A significant change may require referral for a Preadmission Screening and Resident Review (PASRR) evaluation if a mental illness, intellectual disability*, or condition related to intellectual disability is present or is suspected to be present + The nursing facility must provide the SMH/MR/DDA authority with referrals as soon as the criteria indicating such are evident (see criteria in the following slides) 68 2019 Ascend, A MAXIMUS Company. All rights reserved. 34
MDS 3.0 identifies two types of criteria for understanding when a PASRR Level II is needed Residents who have not had prior PASRR Level II Mental health condition or intellectual disability was not know Residents who have had previous PASRR Level II Disability service needs change Mental health condition or intellectual disability developed Placement needs change 69 2019 Ascend, A MAXIMUS Company. All rights reserved. Residents who have not had a prior Level II MDS 3.0 Guidance provides criteria for For residents who have not had a previous Level II (when to submit a status change Level I) These may or may not result in a Level II evaluation but gives a trained clinical expert (the Level I Clinical Reviewer) the opportunity to assess the information and make that determination 70 2019 Ascend, A MAXIMUS Company. All rights reserved. 35
MDS 3.0 Guidelines for identifying need for PASRR for an individual NOT PREVIOUSLY IDENTIFIED as having a PASRR condition Note: this is not an exhaustive list 1. Resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where dementia is not the primary diagnosis). 2. Resident whose intellectual disability as defined under 42 CFR 483.100, or condition related to intellectual disability as defined under 42 CFR 435.1010 was not previously identified and evaluated through PASRR. 3. Resident transferred, admitted, or readmitted to a NF following an inpatient psychiatric stay or equally intensive treatment. 71 2019 Ascend, A MAXIMUS Company. All rights reserved. Historic provider instructions for Residents who have NOT previously been evaluated through PASRR 1. IDD suspected + Age of onset is unknown or prior to 18/22 = Refer to clinical expert 2. MH behaviors, diagnoses or symptoms (or psychiatric hospitalizations) + It s not situational = Refer to clinical expert 3. MH prescription or prescription change + It s not situational (e.g., COPD and anxiety, situational depression) or dementia = Refer to clinical expert 72 2019 Ascend, A MAXIMUS Company. All rights reserved. 36
Historic provider instructions for Residents who have NOT previously been evaluated through PASRR 1. IDD suspected + Age of onset is unknown or prior to 18/22 2. MH behaviors, diagnoses or symptoms (or psychiatric hospitalizations) + It s not situational =Refer to clinical expert Clinical expert reviews medical records and reports Referral to Level II or rule out of Level II need 3. MH prescription or prescription change + It s not situational (e.g., COPD and anxiety, situational depression) or dementia Can the need for Level II conclusively be ruled out? Is it likely to resolve? Is it a transient reaction to a situational stressor? 73 2019 Ascend, A MAXIMUS Company. All rights reserved. Residents who have had a prior Level II MDS 3.0 NF Provider Guidance About individuals who have had a previous Level II (when to submit a status change Level I) These may or may not result in a Level II evaluation but gives a trained clinical expert (the Level I Clinical Reviewer) the opportunity to assess the information and make that determination 74 2019 Ascend, A MAXIMUS Company. All rights reserved. 37
PASRR decisions for residents who have and have not been previously evaluated through PASRR (MDS 3.0 guidelines) Guidelines for identifying need for PASRR for an individual PREVIOUSLY IDENTIFIED as having a PASRR condition Note: this is not an exhaustive list 1. Resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms. 2. Resident with behavioral, psychiatric, or mood related symptoms that have not responded to ongoing treatment. 3. Resident who experiences an improved medical condition such that the resident s plan of care or placement recommendations may require modifications. 4. Resident whose significant change is physical, but with behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living. 5. Resident who indicates a preference (may be communicated verbally or through other forms of communication, including behavior) to leave the facility. 6. Resident whose condition or treatment is or will be significantly different than described in the resident s most recent PASRR Level II evaluation and determination. (Note that a referral for a possible new Level II PASRR evaluation is required whenever such a disparity is discovered, whether or not associated with a SCSA.) 7. Previous authorization for a time-limited stay has ended 75 2019 Ascend, A MAXIMUS Company. All rights reserved. Historic provider instructions for Residents who HAVE previously been evaluated through PASRR 1. New or increased symptoms or behaviors or diagnosis (including psych hospitalization) + Significant to the extent that Plan of Care will require change 3. Short term stay ending + Needs to remain in NF beyond authorization period 2. Medical condition improving + Plan of Care requires change; or chooses community and needs discharge plan 4. Not responding to the PASRR Plan of Care + Plan of Care requires change 76 2019 Ascend, A MAXIMUS Company. All rights reserved. 38
1. New or increased symptoms or behaviors or diagnosis (including psych hospitalization) + Significant to the extent that Plan of Care will require change Historic provider instructions for Residents who HAVE previously been evaluated through PASRR 2. Short term stay ending + Needs to remain in NF beyond authorization period =Refer to clinical expert Clinical expert reviews medical records and reports Referral to Level II or rule out of Level II need 3. 4. Not responding to the PASRR Plan of Care Medical condition improving + Plan of Care requires change + Plan of Care requires change; or chooses community and needs discharge plan Can the need for Level II Status Change evaluation conclusively be ruled out? Are the person s disability needs met under the current treatment plan? Is the change clearly due to a medical condition (e.g., B12, TSH, UTI, etc.) 77 2019 Ascend, A MAXIMUS Company. All rights reserved. Lunch 78 2019 Ascend, A MAXIMUS Company. All rights reserved. 39
Afternoon Agenda Time Topic 1:00 1:45 Mindla (Mindy) White Health Facilities Division, DIA 1:45-2:00 Break 2:00 2:45 NFMI Compliance 2:45 3:45 PASRR and DHS Investigations 3:45 4:00 Q&A 79 2019 Ascend, A MAXIMUS Company. All rights reserved. Iowa Department of Inspections and Appeals, Health Facilities Division, Survey Trends related to Pre-Admission Screening and Resident Review (PASRR) 80 2019 Ascend, A MAXIMUS Company. All rights reserved. 40
4/12/2019 Preadmission Screening and Resident Review PASRR F644 Coordination. A facility must coordinate assessments with PASRR program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicate testing and effort. Coordination includes: Incoporating the findings from the PASRR level II determination and the PASRR evaluation report into a resident s assessment, care planning and transition of care 1
4/12/2019 F644 cont. Referring all residents with a PASRR level II condition and all residents with newly evident or possible serious mental illness, intellectual or developmental disability, or a related condition for level II Resident Review (the RR part of PASRR) upon a significant change in status assessment. Intent To ensure that the facility coordinates with the appropriate, State-designated authority, to ensure that individuals with a mental illness (MI), intellectual or developmental disability (ICC) or a related condition (RC) receives care and services in the most integrated setting appropriate to their needs. 2
4/12/2019 PASRR Is a federal requirement to help ensure that individuals who have a mental illness, intellectual or developmental disability or related condition are not inappropriately placed in nursing homes for LTC. PASRR requires that 1) all applicants to a medicaid-certified nursing facility be evaluated for a serious mental illness, intellectual or developmental disability, or related condition PASRR process The initial screening is referred to as PASRR Level 1 and is completed prior to admission to a nursing facility. A negative Level 1 screen permits admission to proceed and ends the PASRR process unless a possible serious mental illness, intellectual or developmental disability, or related condition comes to the attention of the NF later. A positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level II, which must be conducted prior to admission to a nursing facility. 3
4/12/2019 PASRR Level II Comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has MI, IDD or a RC determines the appropriate setting for the individual and identifies what, if any, specialized services or Rehab services or community placement supports the individual needs. The facility must notify the state-designated mental health or intellectual disability authority promptly when a resident with MI, ID, or RC experiences a significant change in mental or physical status. PASRR Any resident with newly evident or possible serious mental illness, intellectual/developmental disability, or related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review. 4
4/12/2019 F645 Preadmission Screening for individuals with a mental illness, intellectual/developmental disability, or related condition. A nursing facility must not admit or or after January 1, 1989 any new residents with: -Mental disorder and/or Intellectual disability- make determination if physical and mental condition of the individual requires the level of services provided by NH or requires specialized services. F645 Cont Exception Readmission to a nursing facility of an individual who after being admitted to nursing facility was transferred for care in a hospital 5
4/12/2019 The state may choose not to apply PASRR for anyone Who is admitted to facility directly from hospital after receiving acute inpatient care at the hospital Who requires nursing facility services for condition for which the individual received care in the hospital Whose attending physician has certified before admission to the facility that the individual is likely to require less than 30 days of nursing facility services Probes If the resident s Level II PASRR report identifies specialized services but the resident is not receiving them Is there evidence of Level 1 preadmission screening of residents prior to admission Are there positive Level I requiring Level II process and approved for admission prior to admission to nursing facility If pre-admission screening of residents longer than 30 days 6
4/12/2019 Deficiency Categorizations Level 4-A resident with bipolar disorder did not receive Level II PASRR evaluation and determination. The failure to ensure the Level II was completed prior to admission resulted in the resident no longer receiving needed psychotherapy 4 times per week. The interruption in services caused the resident to relapse into depressive state. Level 3-The facility failed to ensure Level 1 preadmission screening of a new resident for MI/IDD/RC prior to admission. The resident had cerebral palsy, which is a related condition. DeFiciency Categorization cont The lack of preadmission screening resulted in the resident s condition not being identified prior to admission and the resident not being evaluated through the Level II process. The resident did not receive the specialized rehab services that PASRR may have identified, which resulted in functional decline. Level II- Failure to complete Level 1 preadmission screening prior to admission could potentially cause more than minimal harm. 7
4/12/2019 F646 Nursing facility must notify the state mental health authority or state intellectual disability authority promptly after a significant change in the mental or physical condition of a resident who has MI, IDD, or RC. Significant Change-is a significant decline or improvement in a resident s status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting F646 Cont Referral to the State MH/IDD authority should be made as soon as the criteria indicative of a significant change are evident-the facility should not wait until the SCSA is complete. Examples of significant changes-demonstrates increased behavior, psychiatric or mood-related symptoms, symptoms are not responding to treatment. Has improved and changes are added to the care plan. A resident whose condition or treatment is or will be significantly different than described in the resident s most recent PASRR Level II evaluation and determination. 8
4/12/2019 Baseline Care plan-develop within first 48 hours Should include PASRR identified services if any Comprehensive Care Plan should then include PASRR identified services if any Number of citations 644-76 645-17 646-0 9
BREAK TIME 81 2019 Ascend, A MAXIMUS Company. All rights reserved. Overview of PASRR and Nursing Facilities for persons with Mental Illness (NFMI) Individuals who meet NFMI Level of Care 82 2019 Ascend, A MAXIMUS Company. All rights reserved. 41
What is a NFMI/OR PASRR A Level II PASRR Summary of Findings has rendered an outcome that a person must be placed in one of the State s three NFMIs -OR - A nursing facility that has SELF-IDENTIFIED as a facility that has IMMEDIATE ACCESS to the very high level of services that the individual requires This facility CAN and WILL be able to implement the same services that would be required if this person went to a NFMI 83 2019 Ascend, A MAXIMUS Company. All rights reserved. Who receives a NFMI/OR PASRR? + Individuals with a very Serious Mental Illness, often with recent instability and/or hospitalization + Individual that requires a higher level of specialized services than majority of other individuals that have a PASRR condition, (LII individuals) to ensure their safety and well being + Individuals that require licensed professionals such as Psychiatrists, Behavioral Analysts, and Licensed therapists to provide intensive behavioral health services + Individuals who require highly trained staff who are familiar with implementation of Functional Assessments and Behaviorally Based Treatment Plans and are able to manage the complex behavioral needs of the individual 84 2019 Ascend, A MAXIMUS Company. All rights reserved. 42
Who does not receive NFMI/OR PASRR s Individuals who have a Serious Mental Illness (SMI) that has been quite stable over time Individuals with a co-occurring SMI & Dementia, where Dementia has been determined to be the primary focus of treatment and may be ruled out of the PASRR population.* Individuals who can receive standard nursing facility care and specialized services but do not also require intensive behavioral analysis or management. *States do have discretion to keep individuals with primary Dementia in the PASRR population at their discretion & this has happened only rarely in Iowa 85 2019 Ascend, A MAXIMUS Company. All rights reserved. Some Iowa PASRR Data for NFMI/OR Outcomes + There were 97 NFMI/OR PASRR Level II s determined in 2016 + There were 139 NFMI/OR PASRR Level II s determined in 2017 + There were 19,021 Level I screenings completed in 2018 + There were 4553 Level II PASRRs completed in 2018 + There were 88 NFMI/OR PASRR Level II s determined in 2018 These 88 represent 1.9% of the LII population These 88 represent.4% of the LI population There are 168 NFs or NFMI s in Iowa who had accepted individuals with this outcome for placement 86 2019 Ascend, A MAXIMUS Company. All rights reserved. 43
Iowa Map of Locations Where Individuals with NFMI LOC are Placed 87 2019 Ascend, A MAXIMUS Company. All rights reserved. Goals of the NFMI/OR Outcome The intensive Behavioral Health services are designed to help reduce the number of psychiatric hospitalizations By means of behavior analysis and proactive management, decrease difficult behaviors with the goal of the individual transitioning to a lower level of care Address issues that may have led to criminal history or trauma that may be related to past abuse as a victim or perpetrator Working with the Psychiatrist and Behavioral Health Team to achieve the optimal medication regimen to achieve stability Evaluate safety needs and provide the level of supervision needed to keep the individual and others safe 88 2019 Ascend, A MAXIMUS Company. All rights reserved. 44
Abuse and/or Criminal histories It is not uncommon for individuals to have criminal histories or other complex legal histories When known or suspected, Ascend will check the Iowa Courts Online and document the findings in the PASRR https://www.iowacourts.state.ia.us It is not uncommon for individuals to have child or dependent adult abuse histories If known or suspected, Ascend will check the Child & Dependent Adult Abuse Registries using: DHS form 470-0643 (Rev.2/16), Request for Child and Dependent Adult Abuse Information If abuse is found or not found, Ascend will insert a phrase in the PASRR encouraging treatment providers to check these registries using the form above, such that issues arising from any abuse history can be addressed in treatment 89 2019 Ascend, A MAXIMUS Company. All rights reserved. Nursing Facility for Persons with Mental Illness Also known in Iowa as ICF/PMI Intermediate Care Facility for Persons with Mental Illness Highly Specialized NF for residents who need intensive behavioral health services and behavior management Typical Services Identified are as follows: Frequent and Ongoing psychiatric services by a psychiatrist to evaluate response and effectiveness of psychotropic medications on target symptoms, modify medication orders, and to evaluate ongoing need for additional behavioral health services. A Functional Assessment of maladaptive behaviors by a Behavior Analyst or Qualified Behavioral Health Professional with equivalent experience. A behaviorally-based treatment plan to include both routine and crisis related behavioral supports developed with assistance from a Behavior Analyst or Qualified Behavioral Health Professional with equivalent experience 90 2019 Ascend, A MAXIMUS Company. All rights reserved. 45
Typical Services Identified for NFMI PASRR, continued Individual Therapy by a Licensed Behavioral Health Professional Group Therapy by a Licensed Behavioral Health Professional Development of a Behavioral Health Advance Directive (Such as WRAP) with support from a Certified Mental Health Peer Support Specialist Pursuit of Legal Guardianship and/or Conservatorship through the court NFMI/or Outcomes are also often for Short Term Approval such that proactive planning for transition to a lower level of care with intensive services/supports is not uncommon 91 2019 Ascend, A MAXIMUS Company. All rights reserved. Functional Assessment + If you are not familiar with Functional Assessments and how to get them done, that s a good indicator that you are not ready to accept someone with a this outcome + You ll be expected to show the actual completed Functional Assessment to Ascend/DHS, MCO, DIA, and/or LTC Ombudsman (I.e. Service Matters) + The Functional Assessment Identifies and Measure the triggers for this individual that lead to behaviors (antecedents) + Frequency / Intensity / Duration of behaviors + What works to diminish behaviors (reward/consequences) + What does not work to diminish behaviors(rewards/consequences) + Behavior logs are used to document date, time, duration, and antecedent of the behaviors, actions taken by staff, and outcomes 92 2019 Ascend, A MAXIMUS Company. All rights reserved. 46
Behaviorally Based Treatment Plan + A Functional Assessment of Maladaptive Behaviors must be conducted in order to create the Behaviorally Based Treatment Plan + What are the specific behaviors being targeted + What are the interventions needed when the behaviors occur + Need for safety plan to respond to: Self harm + Violence to others + Smoking + Sexual aggression + Guidance on when to seek psychiatric hospitalization + Elopement + Identify who should initiate the interventions (be specific) + Frequency of the plans being reviewed for effectiveness + Log for tracking use of interventions + Information about Behavior Analyst and Licensure + https://www.legis.iowa.gov/docs/publications/lge/87/sf192.pdf 93 2019 Ascend, A MAXIMUS Company. All rights reserved. Some Resources from the PASRR Website! All of these items can be found on the PASRR Providers Website: http://www.pasrr.com/iowadefault.aspx Under Educational Tools Webinar Slides - PASRR-Identified Services of Crisis Intervention Plans, Safety Plans and Behavioral Health Advance Directives (3/29/2016) Webinar Slides - Behaviorally Based Treatment Plans & Specialized Services by Susan Smith (3/15/2016) Template - Routine and Crisis Behaviorally Based Treatment Plan Webinar Slides - Behaviorally Based Treatment Plans by Susan Smith (2/23/2016) 94 2019 Ascend, A MAXIMUS Company. All rights reserved. 47
What to Do Before Accepting an Individual with a NFMI/OR Outcome Your Administration must determine if you wish to self-select as a NF that can offer these services and accept individuals with a NFMI/OR Outcome Read the PASRR! + Locate and confirm your ability to implement specific, intensive specialized services identified in the summary of findings PRIOR TO admission + Make certain that you have access to a Psychiatrist who will agree to accept these patients, or make arrangements with their current psychiatrist to keep seeing them + Confirm Behavior Analyst or Train staff on how to conduct Functional Assessments of Maladaptive Behaviors + Confirm Behavior Analyst or Train staff on how to write and implement Behaviorally Based Treatment Plans + Ensure Immediate access to behavioral health resources, disability-specific services and supports + Ensure that staff have immediate access to a highly individualized Behaviorally Based Treatment Plan for this individual 95 2019 Ascend, A MAXIMUS Company. All rights reserved. By accepting an individual with a NFMI/OR Outcome you are acknowledging that: +You can provide all the services identified in the PASRR upon admission +You can meet the person s needs relating to supervision and safety upon admission +You will have PASRR compliant care plan, Psychiatry, Functional Assessment, and Behaviorally Based Treatment Plan in place within days of placement, along with all other identified services +You have staff fully trained and ready to consistently implement supervision, safety measures, FAs, BBTPs, and behavioral interventions 96 2019 Ascend, A MAXIMUS Company. All rights reserved. 48
What to do if you can no longer support the individual + Prevention is the best medicine Decide on the front end if your facility wants to self-select into the small group of facilities that can support this person + If a hospital is attempting to do an exemption and the individual may qualify for a NFMI/OR ask for a full Level II evaluation. + Contact your Ombudsman to advocate on behalf of the individual and the facility + Contact the individual s MCO care manager + Plan proactively so as to avoid hospitalization and/or destabilizing the individual in other ways + Document, Document, Document + Contact a NFMI Facility 97 2019 Ascend, A MAXIMUS Company. All rights reserved. NFMI/OR Trends, Service Matters Compliance concerns + NF does not arrange for or begin providing services until a Service Matter review has been initiated + NF does not promptly implement services when the period of approval is short. I.E. 90 days or less + NF does not promptly complete an Admission notice in PathTracker Plus (must also elect NFMI as LOC!) + Many NFs do not know how to coordinate the (NFMI LOC) specialized services and locate specialized providers prior to admission + NF fails to understand that (NFMI LOC) specialized services cannot be completed by untrained / unlicensed staff within the nursing facility + NF fails to provide the FA and the BBTP as part of the review + NF fails to develop a PASRR compliant care plan that includes the name and credentials of the provider, duration, frequency and start date of each PASRR identified service 98 2019 Ascend, A MAXIMUS Company. All rights reserved. 49
NFMI/OR & Service Matters Continued +The care plan is not written specifically for the individual and include interventions that are detailed, and targets the individual s specific needs (cannot be generic) +The care plan does not suggest that the facility has taken into account how to ensure the safety of the individual or others +There is a lack of capacity and a showing of how behaviors will be measured and tracked (ABC Antecedent, Behavior, Consequence) +NF often fails to employ & document the help of disability expects in IDD, substance abuse, TBI, etc. +The BBTP is often not aligned with information that the functional assessment (FA) contained/identified 99 2019 Ascend, A MAXIMUS Company. All rights reserved. Nursing Facility for Persons with Mental Illness + Facility Specific determination + [approval] of admission to either (1) a Nursing Facility for persons with Mental Illness (NFMI) or (2) a nursing facility that identifies that they have immediate access to behavioral health resources, disability-specific services and supports, and must confirm the ability to implement the specific, intensive specialized services identified in the attached summary of findings. Among the many specialized and rehabilitative services as well as community placement supports that any PASRR may identify and require, the nursing facility staff should be familiar with developing, in collaboration with a behavior analyst, a functional assessment and behaviorally-based treatment plan to address + Individual approved only for + Identified facility + NFMI facilities are: + Davis Center, Bloomfield + Southeast Iowa Behavioral Healthcare Center (Formerly known as Dave s Place), Keokuk + Black Hawk Nursing and Rehab (Formerly known as Country View), Waterloo 100 2019 Ascend, A MAXIMUS Company. All rights reserved. 50
What is expected of the NFMI Facilities +The NFMI Facilities and facilities who accept individuals who meet NFMI LOC are expected to: +Have a psychiatrist on staff or readily available +Have Behavior Analyst or Qualified Behavioral Health Professional with equivalent experience on staff or readily available +Have expertise at developing exceptional functional assessments for maladaptive behaviors and behaviorally based treatment plans +Have staff trained in how to reduce challenging behaviors and help the individual transition to a lower level of care 101 2019 Ascend, A MAXIMUS Company. All rights reserved. Other Special Issues Arising with individuals who meet NFMI/OR Level of Care (LOC) +An individual who is identified for a NFMI must be 65 years or older Federal Requirement Medicaid can t pay for placement in a NFMI for anyone under 65 +The Individual must have a Serious Mental Illness and not be ruled out of PASRR population due to a Dementia that has become the primary focus of treatment +If/when the PASRR includes a notation advising a check of the child and/or dependent adult abuse registries, it is imperative that the NF check the registry for issues relating to behaviors/management +Also imperative for NF/NFMI to advise the treating therapist and other BH providers to check the abuse registries for information that will be relevant to treatment 102 2019 Ascend, A MAXIMUS Company. All rights reserved. 51
Where to Find the NFMI/OR NF Determination in the Summary of Findings 103 2019 Ascend, A MAXIMUS Company. All rights reserved. Admission Notice IMPORTANT! On the Admission Notice that the facility submits to PathTracker, you MUST indicate that the individual is at the NFMI Level of Care 104 2019 Ascend, A MAXIMUS Company. All rights reserved. 52
PASRR for individuals with a history of Dependent Adult Abuse 105 2019 Ascend, A MAXIMUS Company. All rights reserved. Learning Objectives Offer PASRR Community SOME BASICS on Dependent Adult Abuse overlay with PASRR + Independent Contractors who do face to face interviews with individuals and collaterals + Quality Reviewers, in Tennessee, who finalize PASRR LII Summaries and identify services + Hospital and Nursing Facility Staff who submit PASRR LI screens, read LII Summaries, and arrange service delivery + Address when to report existence of possible abuse and/or criminal/court histories + When PASRR requests Abuse information, what happens with it? + Why court orders and legal/criminal history become important matters in such cases Role of Guardianship & Conservatorship in both processes 106 2019 Ascend, A MAXIMUS Company. All rights reserved. 53
When is PASRR required? (When) The Preadmission Screen PAS is required PRIOR to placement in a NF Failure to have the PASRR completed prior to admission can result in non-payment, and is a licensing issue for Dept. of Inspections and Appeals Resident Review RR- PASRR whenever certain Status Change criteria is met Turnaround times for PASRR: Web Approved Level Is immediate Clinician Reviewed Level I s or Categorical Exemptions are an average of 8 business hours Full Level II assessments are an average of 5 calendar days If a PASRR requires DAA information, this will result in it taking longer to complete For Individuals who are likely to trigger a full LII assessment, which includes many of the individuals for whom Dependent Adult Abuse Assessments are conducted, It Is Important To Plan Ahead 107 2019 Ascend, A MAXIMUS Company. All rights reserved. Resident Review / Significant Status Change Nursing Facility Level I Disability Screen Level II In-Depth Evaluation Determination & Notification = Summary of Findings Other Appropriate Placement 54
PASRR in Iowa Ascend, a Maximus Company (Where) + Iowa has contracted for PASRR with Ascend/Maximus since 9/1/2011 + Ascend/Maximus is located in Franklin, TN + Iowa PASRR Website: http://www.pasrr.com/iowadefault.aspx + The Iowa PASRR submission process is 100% online, available 24/7/365 + Iowa PASRR Provider enrollment is FREE and available to anyone 109 2019 Ascend, A MAXIMUS Company. All rights reserved. PASRR in Iowa Ascend, a Maximus Company (Where) Continued + 75% of PASRRs are web approved + 18% of PASRRS are categorical or clinician approved 7% of PASRRs require full Level II face-to-face assessment + Independent Contractors who do face-to-face interviews are all based in Iowa + Interviews take place wherever the person is located; PAS is frequently at a hospital Home, Assisted Living, NF, Group Home 110 2019 Ascend, A MAXIMUS Company. All rights reserved. 55
What is needed for a thorough Level II evaluation (How) A Level I submitter with access to Ascend/Maximus enters the L1 information into the system, answering all questions in the web based system + Psychiatric Diagnoses, Medications, Symptoms, & History + Medication Administration Record + History & Physical + Recent history of housing, placement, substance use, other factors that inform the process + Physical health issues, ADLs, IADLs to address level of care A clinical review is completed and determines if further evaluation (Level II) is needed 111 2019 Ascend, A MAXIMUS Company. All rights reserved. 56
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What is needed for a thorough Level II evaluation (How) Continued Face-to-face interview with Individual, Caregivers, Legal Guardians or Substitute Decision Makers is conducted by an Ascend Independent Contractor (AKA Assessor) + (Iowa-based Independent Contractors with Ascend) If DHS is involved, interview with Adult Protective Services Worker can be very useful Abuse history, criminal, & other legal history is crucial + Often, there is recent guardianship/conservatorship activity + Court orders pertaining to placement &/or guardianship are essential + PASRR LII will determine Level of Care, so it is important that courts know that + For other non-lii individuals on Medicaid, Iowa Medicaid will determine LOC 118 2019 Ascend, A MAXIMUS Company. All rights reserved. 59
Dependent Adult Abuse Assessment: IMPACT on PASRR Whenever : 1. Someone is submitting the Level I information into the PASRR database, they report some knowledge that a past history exists or current assessment pertaining to abuse is underway 2. Information is reported that suggests that an individual may have a criminal or abuse history pertaining to child or dependent adult abuse as a victim or perpetrator 3. Situations arise during the course of data collection and interviews for PASRR LII, where alleged abuse has or is taking place 4. In the course of data collection and interviews for PASRR LII, The Independent Contractor obtains information that allegations of abuse may currently be under investigation by DHS 5. In reviewing records that have been attached to a PASRR that is currently under review, it is revealed that a past history of abuse exists or may exist, and/or that a current matter may be getting addressed by DHS in the form of an assessment In ALL of these, and potentially other ways, if there MAY be a current or past history of abuse, PASRR will submit the DHS Form 470-0643 request for Child/Dependent Adult Abuse History, check the sex offender registry, and check Iowa Courts online for other court/criminal history. 119 2019 Ascend, A MAXIMUS Company. All rights reserved. Intra-Agency Collaboration is Best Practice Both the Child/Dependent Adult Abuse program & PASRR are statutory requirements for the Department. Accordingly, Child & Dependent Adult Abuse information and PHI can be exchanged between agency staff on a need to know basis. + Iowa Code 235B.5(6) + Iowa Code 217.30(4)(a) + Iowa Code 235B.6(2)(e)(2) 120 2019 Ascend, A MAXIMUS Company. All rights reserved. 60
Sharing of Abuse Information With Others Ascend, A Maximus Company as a DHS contractor for PASRR, has access to Confirmed & Founded Child &/or Dependent Adult Abuse information. To request information, EACH providers (NFs, therapists, behavioral health providers, and other service providers) must submit: DHS Form 470-0643 (Request for Child/Dependent Adult Abuse History) The Child/Dependent Adult Abuse registry will determine appropriateness of request and provide any information that is available on confirmed, or founded abuse Note: Abuse information CANNOT be re-disseminated 121 2019 Ascend, A MAXIMUS Company. All rights reserved. ADULT PROTECTIVE SERVICES INFORMATION 122 2019 Ascend, A MAXIMUS Company. All rights reserved. 61
What are Adult Protective Services in Iowa Generally referred to Dependent Adult Abuse Assessments or Evaluations. IT IS THE LAW (Iowa Code 235B) and requires the Iowa Department of Human Services to establish and operate a dependent adult abuse services program that shall emphasize the reporting and evaluation of cases of abuse of a dependent adult who is unable to protect the adult s own interests or unable to perform activities necessary to meet essential human needs. 123 2019 Ascend, A MAXIMUS Company. All rights reserved. Terms in Adult Protective Services- APS (What) Dependent adult means a person 18 years of age or older who is unable to protect the person s own interests or unable to adequately perform or obtain services necessary to meet essential human needs, as a result of a physical or mental condition which requires assistance from another, or as defined by departmental rule. Caretaker means a related or nonrelated person who has the responsibility for the protection, care, or custody of a dependent adult as a result of assuming the responsibility voluntarily, by contract, through employment, or by order of the court. 124 2019 Ascend, A MAXIMUS Company. All rights reserved. 62
Terms in Adult Protective Services- APS (What) continued Dependent Adult Abuse means any of the following as a result of acts or omissions of a caretaker: + Physical Abuse (includes verbal assault). + Sexual Abuse + Sexual Exploitation + Exploitation of Physical or Financial Resources + Deprivation of Food, Shelter, Clothing, Supervision, Physical or Mental Health Care, or Other Care necessary to maintain the DA s life and health as a result of acts or omission by Caretaker. + Deprivation of Food, Shelter, Clothing, Supervision, Physical or Mental Health Care, or Other Care necessary to maintain the DA s life and health as a result of acts or omissions by the Dependent Adult. 125 2019 Ascend, A MAXIMUS Company. All rights reserved. What Dependent Adult Abuse IS NOT + IT IS NOT Elder Abuse (Iowa Code 235F) + Dependent Adult (DA) declines medical treatment because of DA s religious beliefs. + Caretaker not providing Medical Treatment because of DA s religious beliefs. + Withholding/Withdrawing health care from DA because of terminal illness diagnosed by licensed physician. + Abuse that occurs in a nursing facility through acts or omissions by staff may be abuse but it is solely handled by Iowa Department of Inspection and Appeals (Iowa Code 235B.3) 126 2019 Ascend, A MAXIMUS Company. All rights reserved. 63
What are Dependent Adult Assessments vs. Evaluations Assessments are conducted when allegations of abuse are believed to be a result of the dependent adult s acts or omissions. Evaluations are conducted when allegations of abuse are believed to be a result of acts or omissions by a caretaker. 127 2019 Ascend, A MAXIMUS Company. All rights reserved. Who Conducts Adult Assessments or Evaluations DHS staff referred to Adult Protective Service workers (APS). APS are charged by law to: + Observe and Interview the DA + Determinate initial safety and welfare status of DA Involve appropriate law enforcement and medical personnel. Consult with county attorney and take emergency action in Iowa District Court when necessary. + Gather Information about allegation through: Interview of Caretaker (when conducting an evaluation). Collateral Contacts Gathering financial and medical documentation relevant to allegation. + Arrange for services needs. 128 2019 Ascend, A MAXIMUS Company. All rights reserved. 64
How PASRRs with Dependent Adult Abuse IMPACT the NF + When PASRR has identified that there MAY be a Dependent Adult Abuse history (or a child abuse history) - Specific abuse information CANNOT be shared in the PASRR + When any collaboration with DHS has taken place in the PASRR - The first paragraph will note Iowa DHS as among the sources of information for that PASRR. + When Abuse History has been alleged to exist, the PASRR legal history section will include : A check of child and/or dependent adult abuse history was made using DHS Form 470-0643. As information relating to this check cannot be shared, any providers of behavioral health services who may be involved in treatment, as well as other care providers engaged in the arrangement of services or discharge planning, are encouraged to perform a check of child and/or dependent adult abuse history, using DHS Form 470-0643, Request for Child and Dependent Adult Abuse Information. + The PASRR legal history section will also include a check of Iowa Courts Online and the Iowa Sex Offender Registry as a standard protocol. + The section of the PASRR LII Summary where PASRR identified services are included, will also use the statement above, to add emphasis to the fact that behavioral health providers, in particular, are encouraged to check the abuse registries for any reports that may exist and be available to them, so the issues can be addressed in treatment. 129 2019 Ascend, A MAXIMUS Company. All rights reserved. Contact Information Lila P.M. Starr PASRR Program Manager Older Adult Mental Health Specialist Iowa Department of Human Services Division of Mental Health and Disability Services 1305 E. Walnut Hoover Building, 5 th Floor Des Moines, IA 50309 lstarr@dhs.state.ia.us 515-281-5318 DHS Help Desk for Adult Protective Service Workers: 866-347-7782 These materials will be added to the DHS training site To Report Possible Child or Dependent Adult Abuse in Iowa: 800-362-2178 For information and training on Iowa PASRR: www.pasrr.com/iowadefault.aspx 130 2019 Ascend, A MAXIMUS Company. All rights reserved. 65
Iowa PASRR Compliance!! Failure to complete a PASRR prior to admission to the nursing facility.!! Failure to secure an approved (new) PASRR prior to a expiration of a categorical and / or other short term PASRR approval. (example # 1).!! Failure to submit a new Level I screening when the individual meets the criteria for a significant change in status. (example # 1)!! Failure to ensure the PASRR remains in the active chart. (Unicorn)!! Failure to ensure that the PASRR is a clinically accurate representation of the individual. (example # 1).!! Failure to review PASRR prior to placement to ensure that the facility has the capacity to deliver identified services. (possibly examples 1, 2, & 3). 131 2019 Ascend, A MAXIMUS Company. All rights reserved. Iowa PASRR Compliance Continued!! Failure to complete a PASRR Compliant Care Plan, with all four required elements. (example # 1, 2 & 3).!! Failure to provide evidence of service delivery / coordination of PASRR identified Specialized Services. (example # 1, 2 & 3).!! Failure to actively care plan and conduct discharge planning for individuals with high potential for discharge into the community. (example # 1, 2 & 3).!! If the facility fails to reach out to the MCO, options counselors, case managers and other service providers that support discharge planning is a factor that contributes to non-compliance. Complete an Admission Notice, Discharge Notice or Transfer timely. (example # 1 & 2).!! Do not admit someone into PathTracker in order to complete a Level I PASRR Screening.!! Use the correct Admission Date. (Example # 3)!! Use accurate provider/npi numbers!! If you don t admit the person, don t submit an admission notice.!! No Discharge notice is needed if the person goes to the hospital for less than 10 days!! Nursing facilities should not complete a paper version of the Change Activity Report (CAR) 132 2019 Ascend, A MAXIMUS Company. All rights reserved. 66
Follow this link to print your Certificate of Attendance https://www.surveymonkey.com/r/iaspringpasrr2019certificate IA Nurses If you are obtaining CEUs as a nurse in IA through the IBON, you do not need to print a certificate of attendance. You will receive your CEU in the mail in June 2019. Remember, you MUST sign in AND out at the registration table to obtain CEUs. Failure to do so will prevent CEU award. No partial CEUs will be given. 133 2019 Ascend, A MAXIMUS Company. All rights reserved. 67
TRAINING EVALUATION FORM The following survey asks questions related to your impression of the content and delivery of PASRR Provider Training presented by Ascend, a MAXIMUS Company and the IA Dept of Human Services, DMHS. Provide thoughtful and professional feedback to assist us in improving the quality of future presentations available to you. Strongly Agree Neutral Disagree Strongly Agree Disagree 1. The training met my expectations. 2. The content provided is relevant to my work. 3. I will be able to apply the knowledge learned. 4. The content was organized and easy to follow. 5. The trainer was knowledgeable. 6. The quality of instruction was good. 7. The training objectives for each topic were identified and followed. 8. The trainer met the training objectives. 9. Adequate time was provided for questions and discussion. Excellent Good Average Poor Very Poor 10. Provide an overall rating What aspects of the training could be improved? Other comments? *What happens to this evaluation: The presenter will receive all feedback in a summary document that does not include names. Provide professional input about how the presentation was effective or could have been more effective in a way that encourages professional growth. Nurses: You may submit this evaluation directly to the IA Board of Nursing IBON #94