Iowa Department of Human Services

DATE: June 4, 2012 Iowa Department of Human Services Terry E. Branstad Kim Reynolds Charles M. Palmer Governor Lt. Governor Director TO: FROM: RE: General Hospital, Nursing Facility and Skilled Nursing Facility Providers DHS, Mental Health and Disability Services Division (MHDS) DHS, Iowa Medicaid Enterprise (IME) Level I and Level II process for Preadmission Screening and Resident Review (PASRR) Iowa DHS continues to work with providers to identify and answer questions regarding the Iowa Level I and Level II PASRR processes. As frequently asked questions from providers are identified, DHS and Ascend will develop responses and publish answers. The following questions were identified in the months after the new electronic Level I system went live January 9 th. These responses will be posted to the website as part of the FAQ document. Iowa DHS encourages providers to learn about the Level I and Level II processes through viewing the PASRR Training video and reading the PASRR Provider Manual and the FAQ documents, both located at www.pasrr.com (Iowa PASRR). 1. Weekend Level II evaluations: How do Level II evaluations get assigned on weekends? Level II evaluations begin with Level I screens that indicate a suspicion of a PASRR condition. Iowa DHS has contracted with Ascend to implement a 24/7 web-based PASRR Level I screening system. Some Level I screens lead to an automated Level I approval. However, if a Level I screen requires further review, Ascend is contracted to complete the review of the Level I screen within 8 business hours. When a Level I screen suggests the need for a Level II onsite evaluation, Ascend assigns the onsite Level II evaluation to one of their trained PASRR professional assessors. Onsite assessors are available to conduct Level II evaluations during typical business hours and also make themselves available on weekends and after typical business hours, when necessary and appropriate for the individual. By contract, Ascend must complete evaluations within 5 calendar days. Ascend has consistently met contracted average turn-around times. When a Level I screen that is submitted after hours triggers a Level II evaluation, Ascend will review the Level I the next business day and assign the evaluation to a PASRR professional as soon as possible the next business day. Assessors respond to referrals within a few hours in order to assist Ascend in identifying an available assessor in a timely fashion. Regardless of the time is takes for an assessor to be identified, the assessment is due within 5 calendar days from the date the need for a Level II was identified. 1305 E. Walnut Street, Des Moines, IA 50319-0114

2 2. Do hospitals or emergency rooms receive payment when persons ready for discharge to a NF are not yet approved to admit to an NF because required PASRR activity is not complete? No additional payment is available as the stay is covered under the DRG, unless the stay meets the threshold for cost or day outliers. Critical Access Hospitals are reimbursed at 100% of their cost after the annual cost settlement, so any expenses incurred will be built into the next year s per diem. For persons in the ER, you may be able to hold them for observation, and observation time is reimbursable on an outpatient basis. 3. What are the credentials for Ascend s Level II assessors? The assessors who will complete Level II face-to-face evaluations will be mental health and disability professionals who meet federal QMHP and QMRP criteria and who meet the state s professional credentialing requirements for mental health or disability evaluations. For further clarification, the following is taken from the policy and procedures documents pertaining to Ascend s contract with DHS. Licensure Requirements: The following licensed professionals who have a current license in the State of Iowa, two years post degree supervision by a licensed professional, and a minimum of two years experience working with individuals who have a mental health diagnosis and/or intellectual/developmental disability:* Medical doctor or doctor of osteopathic medicine* Licensed Registered Nurse* Licensed Independent Social Worker (LISW)* Licensed Mental Health Counselor (LMHC)* Qualified Mental Health Professional (QMHP)* Licensed Psychologist (PhD, PsyD) Qualified mental health professional (QMHP) means a person who: 1. Holds at least a master s degree in a mental health field, including but not limited to: psychology, counseling and guidance, nursing and social work; or is a doctor of medicine (M.D.) or a doctor of osteopathic medicine and surgery (D.O.); and 2. Holds a current Iowa license when required by the Iowa licensure law; and 3. Has at least two years of post-degree experience, supervised by a mental health professional, in assessing mental problems and needs of individuals and in providing appropriate mental health services for those individuals. As such, licensed professionals such as Licensed Marriage and Family Therapists (LMFT), Licensed Master Social Workers (LMSW), and Licensed Clinical Social Workers (LCSW) may also meet credentialing requirements for conducting PASRR assessments.

3 In addition, the Department has approved Ascend to utilize non-licensed Master s level professionals with two years experience working with individuals who have a mental health diagnosis and/or intellectual/developmental disability. Candidates who meet these criteria are reviewed and approved by the Department on a case by case basis. IQ Testing: To conduct IQ testing in Iowa, must have a minimum of two years experience conducting testing with supervision and meet Iowa criteria for Psychologist II, III, or IV. 4. Are the assessors required to have their immunizations up to date to visit individuals in the hospital and nursing facility settings? PASRR assessors conduct administrative review activities and do not provide therapeutic interventions, and as such are not subject to provider immunization requirements. 5. It is unclear when the Practitioner Certification form is needed. There is a hyperlink on Ascend s LOC form in WEBSTARS, indicating that I may need this form completed. However, when I look at the Ascend website later, it shows that my Level I screen is complete and no Level II evaluation is needed even though I hadn't yet sent the form in. Whenever an individual has a possible or suspected PASRR condition, the Level I screen submitter has a choice to make. The choice depends on the answer to the question: Do I think that this person might qualify for abbreviated PASRR Level II activity? Abbreviated Level II activity can often be completed in a matter of hours versus the multiple days required to conduct a full onsite Level II evaluation. If the Level I screen submitter believes that the individual may qualify for abbreviated Level II activity, then the submitter indicates this on the Categorical/Exemption page. This page appears only when a Level I screen indicates that an individual may have a PASRR condition. The following seven Federal and State PASRR options are available as abbreviated Level II evaluation activities in Iowa: i. 30-day hospital exemption ii. 60-day convalescent categorical approval iii. Terminal illness categorical approval iv. 7-day Provisional Emergency categorical approval v. 7-day Provisional Delirium categorical approval vi. 30-day Respite categorical approval vii. Severe Illness categorical approval The provider manual posted at www.pasrr.com describes when these abbreviated review options are appropriate. Whenever a Level I submitter requests the 30-day hospital exemption, 60-day convalescent categorical approval, or the terminal illness categorical approval, submission of the Practitioner s Certification form is federally required. On the Level I screen form, the link to the Practitioner Certification form is found only under

4 the these three options for abbreviated Level II activities, as it is only required when a submitter requests one of these three abbreviated Level II options. 6. The first question in the ID/DD section asks if there is a diagnosis of MR. If the answer is no why do we need to complete the rest of the section. Some persons with an intellectual or developmental disability condition do not yet have a diagnosis in their medical record reflecting that condition. The questions on the Level I screen are designed so that Level I screeners can query the record and the individual to determine whether any indicators of a potential intellectual or developmental disability exist, even in the absence of a known diagnosis. 7. If an individual has a primary diagnosis of dementia and therefore excluding the individual from further Level II screening, why is this question not asked first so that the provider does not have to complete the rest of the Level I screen? When diagnoses of dementia and mental illness co-exist, Federal regulation and the guidelines and interpretations of the Centers for Medicaid Services suggest that PASRR programs may not simply accept reports regarding the primacy of dementia over the mental illness condition without question. To exclude an individual from PASRR activities due to primary dementia, PASRR must gather evidence to determine that the dementia is so advanced that the individual would likely no longer benefit from specialized mental health services. Thus, the Level I screen must determine first that the individual has a PASRR condition and co-existing dementia, and secondly must determine the status and progression of the dementia. When a dementia exemption is being considered, the status and progression of dementia must always be completed through a clinical review of evidence regarding the progression of the dementia. This review is completed by Ascend clinicians based on supplemental evidentiary information submitted by the Level I screen submitter. Therefore, the Level I screen could not exclude an individual from further PASRR activity simply on the basis of the way the dementia item on the Level I screen form was answered. 8. Are the questions on the Level I screen set in stone or can changes be made? The Level I form has been vetted and approved by Iowa DHS. Changes to the Level I form are not anticipated. Any changes considered must be vetted by Iowa DHS and must not impact compliance, clinical excellence or operational processes associated with Iowa s PASRR program. 9. Providers, particularly hospital providers, are spending a lot of time looking for patient data that is not found in the medical record. What law/regulation lays out specifically what must be asked/ collected during a Level I screen, or is it at the discretion of the state agency? State agencies must assure that the Level I screen effectively screens each individual seeking admission to a Medicaid certified NF for the potential presence of a disability. The

5 Level I screen adopted by Iowa DHS has been shown to both address federal concerns and meet Iowa s preferences for a disability screen for PASRR purposes. Many hospitals integrate the collection of Level I screening information into the routine patient assessments that occur throughout an individual s hospital stay. This assures that disability screening information is made a routine part of hospital assessments and recordkeeping. Note that when information required on a Level I screen is not yet a part of an individual s medical record, the Level I screener is required to gather the required information from the individual or the individual s caregivers. Absence of disability related information in the medical record does not constitute proof of absence of disability indicators. 10. What is the onsite review process for Ascend s Level II evaluators? It seems different evaluators go about this different ways. All Level II assessors are required to collect and submit a structured set of data points relating to the history, needs, status and disability condition of each individual. Gathering this information often requires interviewing the individual as well as multiple caregivers. Assessors are also required to gather and submit relevant supporting documents from each individual s medical record. However, there is not a mandated order in which assessment interview or record review activities must occur. Level II assessors are clinical professionals trained in the requirements of PASRR who use their clinical and assessment expertise to guide their approach to PASRR assessment activities. 11. Does Ascend have insurance and if so, at what levels? Ascend s insurance coverage meets all requirements outlined in the original Request for Proposal originated by DHS in Iowa for the PASRR project. The contract includes the following language: 1.4 Insurance Coverage. The Contractor and any subcontractor shall obtain the following types of insurance for at least the minimum amounts listed below: Type of Insurance Limit Amount General Liability (including contractual liability) written on occurrence basis General Aggregate $2 Million Product/Completed Operations Aggregate Automobile Liability (including any auto, hired autos, and non-owned autos) Personal Injury Each Occurrence Combined Single Limit Excess Liability, Umbrella Form Each Occurrence

6 Aggregate Workers Compensation and Employer Liability As required by Iowa law As Required by Iowa law Property Damage Each Occurrence Professional Liability Aggregate Each Occurrence Aggregate $2 Million $2 Million 12. Should Ascend s Level II assessors document in a patient s record? Ascend s Level II assessors should not enter information into a patient s medical record. It is also important to know that Federal regulations require nursing facilities to maintain a copy of the Level I screening, PASRR Level I and Level II notification letters, and the Summary of Findings Report in the resident s medical record at all times. The Summary Report identifies any behavioral health treatment and service needs that are the responsibility of the nursing facility staff, as well as any specialized treatment needs. These determination reports are to be used in conjunction with the facility s resident assessment process to define a complete care plan for the resident. Any other documentation regarding the PASRR assessment activities that a facility desires to include in the chart should be entered or recorded by the facility staff. 13. What is the Level I screen submission and LII evaluation process for holidays? What holidays will Ascend be closed? Level I screens may be submitted 24 hours a day and 7 days a week. Many Level I screens lead to an automated Level I approval. When an automated Level I approval applies to a Level I screen submission, the automated approval will be available 24 hours a day and 7 days a week. However, if a Level I screen does not lead to an automated approval, and requires further review by an Ascend clinician, Ascend is contracted to complete the review of the Level I screen within 8 business hours. See answer # 1 in this document for Level II after-hours processes. Holidays will not be considered business hours. Please see Ascend s Holiday schedule posted on www.pasrr.com. 14. What is the PASRR process for individuals in Iowa admitting to NFs in other states? Iowa DHS does not require an individual to go through the Iowa PASRR process if he/she is admitting to a NF in another state. However, the accepting state may have PASRR policies and processes for out-of-state-admissions. The discharging provider will need to communicate closely with the accepting facility to identify the accepting state s PASRR procedures.

7 15. How did Iowa DHS come up with the Level I screening protocol? Where does Iowa s Level I system stand when benchmarking against other states that have implemented PASRR from a data collection and complexity perspective? Iowa s Level I screen is consistent with Level I screening forms used by several states in terms of length, breadth and content. Simplistic Level I screens can both over and underrefer persons for Level II evaluation activity. Some states have chosen to continue to use very short and simplistic Level I screens. However, DHS was not amenable to the clinical and compliance risks associated with those Level I screens. DHS is confident that the Level I screen form chosen for this project achieves a balance between thoroughness, resource use and clinical and compliance risk. It should be noted that in recent reports published by the PASRR Technical Assistance Center (PTAC) in conjunction with CMS, in late 2009 Iowa s PASRR program was found to be in the 3 rd quartile nationally with comprehensiveness of the program in the 26% to 50% range. Updated data from February 2012 shows that Iowa s program is currently considered 100% comprehensive. 16. For states that require less information to be collected, has there been an increase in Level IIs as a result? Information regarding volumes of Level II activity vis-a-vis length of Level I forms adopted by various states is not available to DHS.