MEMORANDUM

To:

PRAT TRAINEES

From:

PAI

Re:

PASRR Legal Requirements

Date:

September 20, 2004

PASRR

I. Introduction

A. What is PASRR?

PASRR is a federally mandated screening and evaluation tool that is used to assess people with mental illness or developmental disabilities who are being considered for nursing facility placements to determine if nursing facility placement is appropriate or if these individuals can be better served in a more integrative setting. The evaluation also determines if the individual needs specialized services to address his/her disability. PASRR is also used to re-assess the needs of existing nursing facility patients whose conditions have changed or stabilized.

PASRR stands for Pre-admission Screening and Resident Review. Under State and Federal Law, PASSR applies to individuals who are: (1) being considered for admission to a nursing facility, or (2) are already residents of a nursing facility and have a significant change in their physical or mental condition.

[Advocacy note: The Regulations do not specify what qualifies as a significant change. We would encourage all advocates to request PASSR evaluations for clients who become stabilized or feel they no longer need to be in a skilled nursing facility. Despite being required to by federal law, many nursing facilities have not been completing reassessments based on a significant change in a resident’s mental health condition. Now that California’s new procedures are in effect, it is important to press nursing facilities to ensure they continue to reassesses the residents when such a change occurs.]

B. What facilities are covered by PASRR?

According to the Federal PASRR Regs (See 42 C.F.R. § 483.102(a)), PASRR applies to any Medi-Cal certified nursing facilities. This includes IMDs as long as at least 1 resident is a Medi-Cal beneficiary (e.g. at least one resident is over 65). Even if a particular resident is not eligible or does not receive Medi-Cal, they are still covered by PASRR if at least one of the other residents is a Medi-Cal beneficiary.

Facilities not covered by PASRR are acute psychiatric facilities (e.g. PHF’s) and ICF/DD facilities.

C. What is PASRR used for?

The PASRR process is used to determine two things: First, whether nursing facility residence is appropriate at all for the individual; and, second, (regardless of whatever residence is determined to be appropriate) what specialized services the individual may need in order to address serious mental illness or mental retardation. For PASRR purposes, mental retardation includes cerebral palsy, epilepsy, autism, or a related condition.

D. How can PASRR help?

Both the Federal Regs and the State’s PASSR Contractor Operations Manual require that community alternatives to nursing placement must be evaluated as part of the PASRR process. Therefore, PASRR can be used to determine if there are better community alternatives for an individual as compared to a nursing facility.

Federal law also requires that PASRR be administered consistently with the requirements of Section 504 of the Rehabilitation Act and the Americans Disabilities Act (ADA). The State has integrated PASSR into its Olmstead plan and has recently amended its PASSR Contractor Manual to include more detailed information about waivers and other community resources.

E. How does the PASRR evaluation process work?

The evaluation process consists of 2 parts: Level I and Level II. Level I is a one-page form which is used to determine if there is a primary diagnosis of serious mental illness or a developmental disability. Patients only move on to Level II if they have such a primary diagnosis. (Please note that mental illness does not include a primary diagnosis of dementia or Alzheimers). The Level II screen consists of a comprehensive physical and mental evaluation of the individual, a determination of whether nursing facility residence is appropriate, alternatives to nursing facility residence if appropriate, and the services which the individual needs for mental illness or mental retardation.

Level I evaluations can be performed by DHS, by staffing at the sending or referring hospital, the treating physician or by the nursing facility staff upon admission.

Level II evaluations are conducted by private contractors pursuant to the guidelines described in the July 2004 PASRR Contractor Operations Manual ("Contractor’s Manual"). Please note that if the patient was referred for a Level II evaluation based on a primary diagnosis of mental retardation, the Regional Center conducts the Level II evaluation.

F. Who participates in PASRR evaluations?

The individual being evaluated must be involved in the evaluation. The individual’s guardian, conservator or other legal representative may also participate. Family members may also participate if the individual or the individual’s guardian, conservator or other legal representative agrees. 42 C.F.R. § 483.128(c)

G. Must the evaluations be culturally competent?

Yes. The evaluation must be adapted to the cultural background, language, ethnic origin and means of communication of the individual being evaluated. 42 C.F.R. § 483.128(b). The new California Level II forms (See Appendix II of the Contractor’s Manual) include questions identifying the language used to administer the evaluation, whether the individual was fluent in that language, whether the individual participated in the evaluation in that language, whether an interpreter was used, etc.

H. Is interdisciplinary coordination required?

Yes. When parts of a PASRR evaluation are performed by more than one evaluator, the state must insure that there is interdisciplinary coordination among the evaluators. 42 C.F.R. § 483.128(d). This requirement is particularly important when the need for community supports and services is being evaluated. This is because the primary evaluator, hospital staff, and nursing facility staff are not likely to have detailed knowledge of the many services which are potentially available in the community.

I. What is the definition of serious mental illness for PASRR purposes?

There is a three part definition:

Diagnosis A diagnosis of: schizophrenia; mood disorder; paranoia; panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another disorder that may lead to a chronic disability. Mental disorder does not include dementia (including Alzheimer’s) unless a mental disorder listed above is the primary diagnosis. 42 C.F.R. § 483.102(b)(2)

Level of impairment: The disorder results in functional limitations in major life activities within the last 3 to 6 months that would be appropriate for the individual’s developmental stage.

Recent treatment/intervention: Within the past 2 years the individual experienced: (1) more than one psychiatric treatment that was more intensive than outpatient care, or (2) at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community, or intervention by housing or law enforcement officials. 42 C.F.R. § 483.102(b)(1)

J. What is the definition of mental retardation (developmental disability) for PASRR purposes?

(1) A level of mental retardation (mild, moderate, severe or profound) as described in the American Association on Mental Retardation’s Manual on Classification in Mental Retardation; or (2) A related condition defined as a severe chronic disability including: cerebral palsy, epilepsy or any other condition (other than mental illness) found to be closely related to mental retardation because the condition results in impairment of general intellectual functioning or adaptive behavior, and requires treatment or services similar to that of persons with mental retardation. (This includes individuals with autism.) 42 C.F.R. § 483.102(b)(3)

This is the federal definition of mental retardation and related conditions. To the extent that California Regional Center eligibility criteria are different, the federal definition controls.

K. Who administers PASRR?

PASRR is a part of the Medi-Cal program. It is required by the federal Nursing Home Reform Act of 1987 (which is part of the Omnibus Budget Reconciliation Act of 1987 "OBRA ’87"). The California Department of Health Services (DHS) has overall responsibility for administration of PASRR just as it does for the rest of the Medi-Cal program.

DHS has entered into a memorandum of understanding with the California Department of Mental Health (DMH) for administration of the PASRR program for individuals with a diagnosis of serious mental illness. DMH contracts with private agencies for PASRR Level II evaluations. Based on the evaluation, DMH is responsible for the final determination of the appropriateness of nursing facility services and the need for specialized services. 42 C.F.R. § 483.106(d)(1)

DHS has entered into a separate memorandum of understanding with the California Department of Developmental Services (DDS) for administration of the PASRR program for individuals with a diagnosis of mental retardation (developmental disability). DDS also administers the program for individuals with a dual diagnosis of both serious mental illness and mental retardation (developmental disability). DDS contracts with Regional Centers for PASRR Level II evaluations and determinations if the onset of the individual’s condition is before age 18. DDS refers individuals to State Developmental Centers for PASRR Level II evaluations and determinations if the onset of the individual’s condition is between age 18 and 22. For individuals who may have both serious mental illness or mental retardation (developmental disability) DDS makes a referral to the appropriate Regional Center or State Developmental Center and also a referral to DMH if needed. 42 C.F.R. § 483.106(d)(2)

PASRR Chart: Individuals being considered for Admission to a Nursing Facility:

PASRR Level I Identification form prepared by hospital, DHS or nursing facility.

May have serious mental illness

May have mental retardation (developmental disability) (or both MR and MI)

No suspected MI or MR

↓ ↓ ↓

Referral to DMH for Level II screen

Referral to DDS for Level II screen

No referral

↓ ↓

DMH refers to contractor for Level II evaluation

DDS refers to Regional Center (if onset before age 18), or Developmental Center (if onset after age 18 but before age 22) for Level II screen—both evaluation and determination. DDS also refers individuals with both MR and MI to DMH if appropriate.

Contractor performs Level II evaluation and refers back to DMH for Level II determination

PASRR Chart: Significant change in a nursing facility resident’s physical or mental condition:

Nursing facility resident with diagnosis of serious mental illness

Nursing facility resident with diagnosis of mental retardation (developmental disability) or both MR and MI

Nursing facility resident with no diagnosis of MI or MR

↓ ↓ ↓

Nursing facility must promptly report significant change in physical or mental condition to DMH. Nursing facility must perform new resident assessment within 14 days of change in condition.

Nursing facility must promptly report significant change in physical or mental condition to DDS. Nursing facility must perform new resident assessment within 14 days of change in condition.

No requirement

↓ ↓

DMH refers to contractor for Level II evaluation

DDS refers to Regional Center (if onset before age 18), or Developmental Center (if onset after age 18 but before age 22) for Level II screen—both evaluation and determination. DDS also refers individuals with both MR and MI to DMH if appropriate.

Contractor performs Level II evaluation and refers back to DMH for Level II determination

L. Where are PASRR requirements found?

The federal statutes governing PASRR are contained in the Medicaid Act, Title XIX of the Social Security Act, at section 1919. That section has been codified as part of the United States Code at 42 U.S.C. § 1396r, specifically 1396r(e)(3)(F) and 1396r(e)(7). Federal regulations can be found in the Code of Federal Regulations at 42 C.F.R. § 483.20(m) and 483.100, et seq.

There are no California statutes or regulations governing PASRR. Specific California PASRR requirements can be found in California’s state Medicaid (Medi-Cal) plan. Requirements for contractors performing level II evaluations for individuals with serious mental illness can be found in California’s Contractor’s Manual.

II. The PASRR Level I Identification

A. What is a PASRR Level I Identification?

A PASRR Level I Identification is a one-page form used to identify individuals who may have serious mental illness, or mental retardation. If an individual may have serious mental illness, or mental retardation, a PASRR Level II screen is triggered. The Level II process is then used to determine, considering a diagnosis of mental illness or mental retardation, whether nursing facility placement is appropriate, and what services the individual needs. 42 C.F.R. § 483.128(a)

B. Who completes the PASRR Level I Identification form?

The PASRR Level I form is completed by one of the following: (1) If the individual is in the hospital and DHS has designated the hospital to complete Level I forms, the Level I form is completed by hospital staff (discharge planners). (2) If the individual is in the hospital and DHS has not designated the hospital to complete Level I forms, the Level I form is completed by the DHS on-site TAR reviewer (if available), otherwise, by nursing facility staff after admission. (3) If the individual has been transferred to the nursing facility from the hospital before the Level I form is completed, or has been transferred directly from the community, the Level I form is completed by nursing facility staff.

C. Where is the completed PASRR Level I Identification form sent?

If the individual is suspected of having serious mental illness, the form is forwarded to the California Department of Mental Health which arranges for a Level II screen for the individual. If the individual is suspected of having mental retardation, (or both mental retardation and serious mental illness), the form is forwarded to the California Department of Developmental Services which arranges for a Level II screen for the individual.

D. Is a PASRR Level 1 Identification always required when an individual is discharged from a hospital to a nursing facility?

No. There are two exceptions to the requirement:

First, a Level I Identification is not required if the individual: (1) was a resident of a nursing facility when hospitalized, (2) has been hospitalized for less than 90 days, and (3) is either returning to that nursing facility or is being transferred to another nursing facility. (However, a new Level II screen is required if there has been a significant change in the individual’s condition.) 42 C.F.R. § 483.106(b)(3)

Second, a Level I Identification is not required if: (1) the individual is being admitted to a nursing facility for care of a condition for which the individual was hospitalized and (2) the nursing facility stay is likely to be less that 30 days. (However, if the nursing facility stay lasts longer than 30 days, a Level I Identification must be done within 40 days of admission.) 42 C.F.R. § 483.106(b)(2)

E. What is the time frame for completing a PASRR Level I Identification?

For new admissions to nursing facilities, California requires that a Level I evaluation be completed on or before the first day Medi-Cal authorization is requested. California’s Medi-Cal Provider Manual P2 (at p.15) notes that Medi-Cal authorization begins on the date the screening is performed and that any days requested prior to the date of the Level I screening will be denied in accordance with federal law. Once the Level I evaluation is completed, it must be forwarded to DDS or DMH (depending on the diagnosis) within 5 days.

Please note that in order to comply with federal law, both the PASRR Level I Identification and the Level II determination must be completed before the individual is admitted to the nursing facility. However, DHS will approve a treatment authorization request (TAR) for nursing facility services for four months pending completion of the Level II determination. It will defer a subsequent TAR until the Level II determination is completed. In effect, this allows the PASRR determination to be completed five months after admission to the nursing facility, rather than before admission to the nursing facility as required by federal law.

We encourage consumers and advocates to push for Level I evaluations during the discharge planning/referral process and to contact Protection & Advocacy if you experience delays.

III. The PASRR Level II Preadmission Screen/Resident Review

A. What is a PASRR Level II Preadmission Screen/Resident Review

The PASRR Level II screen is a comprehensive individualized evaluation of individuals who have been referred for evaluation after a Level I identification. The level II evaluator must obtain a diagnosis of mental illness or mental retardation. If the individual has a diagnosis of mental illness or mental retardation, the evaluator must determine if the individual needs nursing facility level of services. 42 C.F.R. § 483.112(a) The evaluator must also determine whether or not the individual needs specialized services for mental illness or mental retardation. 42 C.F.R. § 483.112(b)

B. When must a Level II Preadmission Screen or Resident Review be performed?

Preadmission screen. Under Federal Law, a Medi-Cal certified nursing facility may not admit individuals with suspected serious mental illness or mental retardation unless there has been a PASRR Level II screen. Typically in California the Level II screen is performed shortly after admission to the nursing facility, but this is not in compliance with federal law.

The California Contractor’s Manual now offers timelines for completion of Level II evaluations. For example, it requires that DMH review a Level I referral within 3 days of receiving it and that referrals are transmitted to the private contractors weekly for performance of level II evaluations. The private contractors then have 7 calendar days (excluding holidays) to complete the Level II screening.

It is our hope that both Level I and II evaluations will be completed in a timely manner now that the new California PASSR procedures are in place. We encourage consumers and advocates to contact Protection & Advocacy if they experience delays in getting complete Level II evaluations.

Resident review. A significant change in physical or mental condition must be promptly reported by the nursing facility to DMH for residents with a diagnosis of mental illness and to DDS for residents with a diagnosis of mental retardation. DMH and DDS, as the case may be, must promptly arrange for the Level II screen. The nursing facility must also conduct a new resident assessment within 14 days of a significant change in physical or mental condition whether or not the resident has a diagnosis of mental illness or mental retardation. 42 C.F.R. § 483.108(c) (Annual PASRR Level II screens are no longer required.)

Under the new California procedures, upon receipt of a change of status Level II referral, the private contractor has 10 calendar days (excluding holidays) to complete and transmit its evaluation to DMH.

Emergency Referrals. Under California’s new procedures for PASSR contractors, upon receipt of an emergency referral, contractors shall complete the Level II evaluations and fax them to DMH within 24 hours. DMH has 3 calendar days to enter, verify, and transmit emergency referrals with the Level II data from the date the referral is received. It is unclear form the Contractor’s Manual or the PASSR regulations what the criteria is for an emergency referral.

C. Who performs the PASRR Level II screen?

Mental illness. The PASRR Level II evaluation is performed by an independent evaluator who has no ties to DMH or to the nursing facility. In California, this is a private contractor. The evaluation is then forwarded to DMH which makes the PASRR Level II determination.

Mental retardation (developmental disability). The PASRR Level II evaluation and determination are performed by the Regional Center for individuals with a condition that has an onset date prior to age 18. The PASRR Level II evaluation and determination are performed by the state Developmental Center for individuals with a condition that has an onset date between age 18 and age 22. If the individual also is suspected of having serious mental illness, a referral is also made to DMH for a Level II screen.

D. What does the PASRR Level II evaluation consist of?

The PASRR Level II evaluation consists of a comprehensive physical and mental evaluation of the individual. The evaluation must be an individualized evaluation. Categorical evaluations are not used in California. 42 C.F.R. § 483.130(b)(1) The findings of the evaluation must be issued in the form of a written report. The following are the basic requirements:

Evaluation The following data elements, at least, must be collected from the evaluation: physical status (diagnoses, date of onset, medical history, prognosis), mental status (diagnoses, date of onset, medical history, likelihood that the individual may be a danger to himself/herself or others), and functional status (activities of daily living). 42 C.F.R. § 483.132(c)

Evaluation of the need for specialized services requires a comprehensive history and physical examination. Federal regulations specify the minimum requirements. 42 C.F.R. § 483.134 (MI), 42 C.F.R. § 483.136 (MR) For individuals with a diagnosis of mental illness, the functional assessment must consider whether the level of support can be provided to the individual in an alternate community setting. 134(b)(5). Although the federal regulations do not contain the same specific requirement for individuals with a diagnosis of mental retardation (developmental disability), individuals with mental retardation (developmental disability) can and most often do receive specialized services in the community.

The evaluation must be based on current level of functioning. 128(h). Preexisting data may be used if it is valid and accurate and reflects the current functional status of the individual. 128(g).

Report "For individualized PASRR determinations, findings must be issued in the form of a written evaluative report which (1) identifies the name and professional title of person(s) who performed the evaluation(s) and the date on which each portion of the evaluation was administered; (2) Provides a summary of the medical and social history, including the positive traits or developmental strengths and weaknesses or developmental needs of the evaluated individual; (3) If NF services are recommended, identifies the specific services which are required to meet the evaluated individual’s needs, including services required in paragraph (i)(5) of this section; (4) If specialized services are not recommended, identifies any specific mental retardation or mental health services which are of a lesser intensity than specialized services that are required to meet the evaluated individual’s needs; (5) If specialized services are recommended, identifies the specific mental retardation or mental health services required to meet the evaluated individual’s needs; and (6) includes the bases for the report’s conclusions."

E. How does the evaluator determine whether nursing facility versus a community placement level of care is appropriate?

First, the evaluator must determine (1) whether an individual’s total needs can be met in an appropriate community setting or (2) whether the individual’s total needs can be met only in an inpatient setting. 42 C.F.R. § 483.132(a)(1) and (2) [Note—this is not a level of care determination. It is a determination as to whether services could be provided in the community whether or not the individual meets level of care requirements for a nursing facility.]

Second, if inpatient care is appropriate, and the individual wants it, the evaluator determines whether a nursing facility is an appropriate setting for meeting the individual’s needs. 42 C.F.R. §§ 483.132(a)(3), 483.126 [Even if it is determined that nursing facility services are appropriate, this regulation specifically provides that the individual may still receive services in the community pursuant to a Medicaid Home and Community-Based Services Waiver. The California Contractor’s Manual, beginning at page 56, includes detailed descriptions of the available Waiver and other community-based programs that PASSR evaluators must consider when appropriate.]

Third, if inpatient care is appropriate, and the individual wants it, but a nursing facility is not appropriate, the evaluator determines whether another facility, e.g. an ICF/DD for an individual with mental retardation, or an IMD for an individual over age 65 with mental illness, would be appropriate. 42 C.F.R. § 483.132(a)(4)

F. How does the evaluator determine the need for specialized services and other services?

First, the evaluator determines whether the individual needs specialized services. An individual who needs specialized services may or may not also need nursing facility level of care.

Second, if the individual is determined to need nursing facility level of services, the evaluator determines whether the individual needs services for mental illness or mental retardation (developmental disability) as the case may be, that are less intense than specialized services. 42 C.F.R. § 483.120(c)

G. What are specialized services?

Each state adopts its own definition of specialized services in accordance with federal requirements. 42 C.F.R. § 483.120(a) California has adopted the following definitions:

Mental illness. "Specialized services is the highest level of mental health therapies and activities prescribed for the treatment of residents experiencing an acute episode of serious mental illness. Specialized services is the continuous and aggressive implementation of an individualized plan of care that:

 

1. Is developed under and supervised by a physician with an interdisciplinary team of qualified mental health professionals.

2. Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness, which requires 24-hour supervision by trained mental health personnel.

3. Is directed toward diagnosis, reduction of behavioral symptoms, improvement in the level of independent functioning, and achievement of a functional level that permits the resident’s return to a lower level of psychiatric rehabilitative services."

Under the California definition, specialized services can only be provided in an acute psychiatric hospital or a psychiatric health facility (PHF). Therefore, specialized services, as defined, cannot be provided in the community or in a nursing facility. However, other community-based services are available for individuals who want to live in the community rather than in a nursing facility.

Mental retardation (developmental disability). "Specialized services for developmentally disabled individuals are defined as services specified by the State which, combined with services provided by the nursing facility or other service providers, result in the continuous and aggressive implementation of an Individual Program Plan (IPP) developed and supervised by an interdisciplinary team that includes a qualified Mental Retardation Professional, the person with developmental disabilities, and where appropriate, the person’s parents, legal guardian, conservator, or other necessary professionals. The IPP goals and objectives should maximize opportunities for the resident to develop relationships; be part of community life in the areas of community participation, housing, work, school, and leisure; increase control over his or her life; acquire increasingly positive roles in community life; and develop competencies to help accomplish these goals. The IPP objectives also should prevent the regression or loss of current optimal functional status. The IPP will specify the type and amount of services and supports to be purchased by the Regional Center or obtained from generic agencies or other resources in order to achieve the IPP goals and objectives. Specialized services are included as provided in the current Regional Center program or fee-for-service Medi-Cal program."

Specialized services under this definition are available in ICF/DD’s and in the community, for example under the Lanterman Act and under the Medicaid Home and Community-Based Services waiver.

H. What happens after the evaluation?

Admission to facility. DMH, the Regional Center or the state Developmental Center, as the case may be, makes a final determination as to whether nursing facility level of services is appropriate. If appropriate, the admission or continued residence is approved. 42 C.F.R. § 483.132(d)

Discharge or transfer from facility. If DMH, the Regional Center or the state Developmental Center, as the case may be, determine that nursing facility level of services is not appropriate, or that services are more appropriate in another setting, DMH or DDS must arrange for discharge or transfer. 42 C.F.R. §§ 483.118(b), 118(c)(2), 483.130(m)

Specialized services. DMH or DDS, as the case may be, must ensure that specialized services are arranged for. If it is determined as a result of the Level II evaluation that the patient needs specialized services, arrangements for specialized services will be made by DMH or DDS in collaboration with the nursing facility, the attending physician, the patient, and the patient’s family or legal guardian. 42 C.F.R. § 483.116(b), 120(b). In the case of specialized services for mental illness, the individual would require transfer to an acute psychiatric hospital or a psychiatric facility in order to receive them.

A nursing facility resident who has resided in the NF for at least 30 consecutive months before the date of the Level II determination, and who requires only specialized services, (but not nursing facility level of services) must be given a choice of remaining in the facility or receiving services in an alternative appropriate setting. 42 C.F.R. §§ 483.118(c)(1) and (2), 483.130(m)

IV. Transfer to a Nursing Facility

A. Readmission. [To the same nursing facility ("NF") following discharge from acute care hospital]: New screen not required unless significant change. (Resident review screen.) In California, an individual who has been out of a nursing facility for more than 90 days is considered to be a new admission. 42 C.F.R. § 483.106(b)(3)

B. Inter-facility transfer. [To new NF with or without an intervening acute care hospital stay]: New screen not required unless significant change. (Resident review screen.) An individual who has been out of a nursing facility for more than 90 days is considered to be a new admission. 42 C.F.R. § 483.106(b)(4)

C. A copy of the current Level II evaluation and determination must be kept in the resident’s chart.

D. NF must transfer copies of most recent Level II evaluation when resident transferred to hosp or another NF.

V. Due process requirements

A. Notice

Level I.

There must be written notice to the individual or legal representative that the individual is suspected of having MI or MR, and is being referred to DMH or DDS, as the case may be, for Level II screening. 128(a). California does not appear to do this.

Level II.

The evaluator must send a copy of the Level II evaluation report to the individual and to the individual’s guardian, conservator, attorney in fact for health care decisions, or other legal representative. 128(k)(1)

DMH/DDS notification of the final determination of PASRR Level II evaluation is made by letter to: 1) the evaluated individual or his or her legal guardian; 2) the patient’s physician; 3) the admitting or retaining NF; 4) the appropriate field office. This does not appear to comply with federal requirements. 42 C.F.R. § 483.130(k), 130(l)

PASRR notices must be adapted to the cultural background, language, ethnic origin and means of communication of the individual being evaluated. 42 C.F.R. § 483.128(b)

B. Hearing

An individual may request a Medi-Cal fair hearing from the California Department of Social Services if the individual is adversely affected by a PASRR determination. (This includes failure to make a PASRR determination when required.) For example, an individual may be adversely affected by a PASRR determination if a nursing facility is not an appropriate living arrangement, or if community alternatives to nursing facility residence, including the availability of community supports and services, have not been adequately considered. 42 C.F.R. § 483.204(a)(2) and 204(b)

C. Denial of FFP for late screens

Federal financial participation is not available for services provided to a nursing facility resident prior to the PASRR Level II determination. 42 C.F.R. § 483.122(b). (Please note that California’s Medical Provider’s Manual allows Medi-Cal authorization to start the day the Level I screening process is initiated.)

D. State tracking

The state must track all individuals with a diagnosis of mental illness or mental retardation (developmental disability) in nursing facilities to insure that appeals and future PASRR reviews take place in accordance with federal requirements. 42 C.F.R. § 483.130(p)

Medi-Cal field offices will review DHS 6170 forms completed by delegated hospitals and NFs to assess the quality of information. The Minimum Data Set (MDS) 2.0 will be reviewed to determine if the assessment is consistent with the Level I screening. The review also will assess the timeliness of Level II referrals and the need for additional training or clarification. Nursing home records are also subject to DHS audit.

 

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