Michelle Newberry Missouri Project Director Bock Associates bockmo@embarqmail.com Kathy Schafer Registered Nurse Clinical Operations Department of Mental Health Kathy.Schafer@dmh.mo.gov Ammanda Ott FAN III -- Facility Advisory Nurse III Department of Mental Health COMRU@health.mo.gov

OBRA 1987 no mandated process for PASRR process 1990 and 1992 regulations granted States enormous flexibility in implementing basic PASRR process Today, CMS is more engaged than ever in promoting

PASRR as a mechanism to improve quality of life for nursing facility residents with disability.

A trend is building for measurement of PASRR quality,

outcomes, and effectiveness art diversion and transition.

Philosophy and attitude has changed with advances in medicine, research and science

“Mental Retardation” and Mental Illness was looked at in past as an infirmity or a lifelong affliction

Focus was on segregated custodial care Today, we know that that with the right

services and supports, individuals with Intellectual, Developmental Disabilities and Serious Mental Illness can be successful living in the community (true to purpose of PASRR)

The goal of PASRR is to ensure that individuals are placed in the least restrictive and most appropriate environment possible. PASRR further ensures that all persons with disability are identified, their needs measured, the full array of needed services and supports are detailed in written recommendations, and that recommended services and supports are delivered.

Federal law requires that a Medicaid-certified nursing facility (NF) may not admit an applicant with serious mental illness (MI), intellectual disability (ID), or a related condition, unless the individual is properly screened, thoroughly evaluated and found to be appropriate for NF placement

560,000 individuals with mental illness in NFs Numbers exceed all other healthcare

institutions combined Mental illness is often a key factor in need for

NF placement NFs serve the same number of persons with

IDD as do large developmental centers Relatively few disability specific or disability

tailored services in NFs

State Medicaid Authority - MO HealthNet State Aging Authority – DHSS

Central Office Medical Review Unit (COMRU) State Intellectual Disability Authority – DMH, Division of DD

State Mental Health Authority- DMH, DBH

The level one screen is completed by Central

Office Medical Unit (COMRU) at DHSS

The level one screen is a screen for individuals who require further evaluation

Capture all persons with suspected or known

SMI, ID, or RC/DD Be sensitive (identify everybody it was meant

to identify) Be specific (include few people who did not

need to be targeted) Helps with effective use of Level II resources

Individuals are referred for Level II Evaluations when the Level I screener finds perplexing records that they could not rule out.

The purpose of the PASRR Level II Evaluation is to

comprehensively assess individuals who are known to have SMI, ID, or a RC, or who met the federal criteria for suspicion and could be affected by those conditions.

The Level II Evaluation is the basis for

determining the individual's needs for care and/or specialized services (SS).

PASRR regulation articulates that determination for placement in a NF "may be considered appropriate only when the individual's needs…meet the minimum stands for admission and… do not exceed the level of services which can be delivered in the NF." New interpretation of SS states that all the unique needs of the individual must be met in the SNF. NF placement is considered inappropriate when community alternatives are available.

Any negative decision can be appealed Appeal requests completed by Federal

Programs Unit at DMH Sent to Division of Legal Services Hearings

Unit DLS will schedule the hearings and notify

parties

(DHSS portion of PASRR screening)

(B) Points will be assessed for the amount of assistance required, the complexity of the care and the professional level of assistance necessary, based on the level-of-care criteria. (C) For individuals seeking admission to a long-term care facility on or after July 1, 2005, the applicant or recipient will be determined to be qualified for long-term care facility care if he or she is determined to need care with an assessed point level of twenty-one (21) points or above, using the assessment procedure as required in this rule.

The DA-124 application will assist in identifying a client that requires a Level II screening.

The DA-124 C form must be completed prior to

admitting the client to a nursing facility to ensure the client does not trigger a Level II screening.

A client that requires a Level II screening cannot be

admitted to the nursing facility prior to the determination of the Level II, unless a valid Special Admission Category (SAC) is submitted.

Level of Care (LOC) is a paper review process. The 21 point count is obtained from the DA 124 application and supporting documentation.

If the application is denied because the application does not meet the mandated 21 point count, then the application is not referred to DMH (Level II can not be initiated).

The application needs to be completed and detailed to avoid delay in processing.

If the application is handwritten make sure the forms are clear and legible.

The client’s social security number is written incorrectly on the applications.

The medication list is not attached or does not contain the dosage and frequencies.

The diagnoses are not listed on the application or attached to the application. (Please do not list the ICD 9 or 10 codes).

The assessed needs section B #16 are not detailed with the client’s needs. A detailed explanation needs to be provided regarding the clients nursing care.

Section B #19 – Forms completed by is not signed

and/or dated.

The assessed needs section B #16 are not detailed with the client’s needs. A detailed explanation needs to be provided regarding the clients nursing care.

Please include the frequency of services. The Assessed Needs must be descriptive for this client. No Point will be assigned for blank areas. Please do not use x1 staff or minimal assistance. Explain exactly what the staff is providing for the client. The clinical information should correspond to Mental Status (Section

#13), Behavioral Information (Section #14), and Functional Impairment (Section #15)

Examples: Client needs assistance with dressing and incontinent of urine Client requires physical therapy 5x weekly See guide #1 on the back of the DA 124 A/B form

Section E must be signed by the legal guardian or the client (if client is own guardian) when the application triggers a Level II screening. When verbal consent is obtained two witness’s signatures are required.

Section F is not signed or dated by the physician (Please include the physician name/license

number). Section F cannot be signed by a Nurse

Practitioner.

Please indicate the client’s current location (client physical location) on the DA 124 A/B form, Section A.

Please attach the Special Admission Category Sheet (located on the DHSS web page) with the DA 124 Application.

If the client is currently inpatient psychiatric, attach the History & Physical and Psychiatric consult to the application. If the client exhibits combative, aggressive or dangerous behaviors, attach a letter of stability from the psychiatric physician.

If additional information is requested, please send to COMRU as

soon as possible. For applications that trigger Level II screening, please notify

COMRU in writing if the client discharges or changes location so that the Level II process can continue.

The hospital needs to send the processed

forms to the accepting nursing facility. Please do not send duplicate applications to

COMRU (If it is emailed, please DO NOT mail the

application).

Stats for May 2014 COMRU processed Level of Care for 1,158 forms COMRU sent 145 forms to DMH for Level II screening DMH determined 48 forms were No Level II required at this time. DMH/Bock determined: 60 were Seriously Mentally Ill 6 were Not Seriously Mentally Il 42 were Intellectual Disabled/RC 9 were Not Intellectual Disabled/RC 8 were Dementia Please note that some application require a MI and ID Level II

screening

When DMH refers a PASRR Level II evaluation to Bock Associates, project staff will verify locations and facility contact person, then assign a Registered Nurse assessor to complete an on-site PASRR Level II evaluation in accordance with CFR 483.134.

Using the information gathered as part of the Level II evaluation, the assessor will make clinical judgments and recommendations regarding the individual's need for specialized services and to identify service needs of a lesser intensity which will serve as the basis for a decision related to the appropriateness of placement.

When the evaluation is complete, the assessor

will return the Level II evaluation packet to Bock Associates' Jefferson City office.

The evaluation packet will then be reviewed under Bock Associates' Quality Assurance Program.

All PASRR/MI evaluations must be reviewed by a contract physician in accordance with CFR Section 483.134 (c).

For each Level II evaluation completed, Bock Associates will generate a "PASRR Level II Determination Sheet" to be returned to DMH.

Bock Associates will forward copies of the Level II Evaluation (or summary) to the individual, the nursing facility, the attending physician and hospital (if appropriate) as mandated in the regulations (CFR 483.130 (k)) .

Upon receipt of the "PASRR Level II Determination Sheet" from DMH, COMRU will issue the written notification to required parties regarding NF admission eligibility, required services, and appeal rights.

The Level II Evaluation protocol is the primary tool that will be used by the assessor to collect critical demographic, medical and psychosocial data, historical information, interview results and observations, as required by Section 483.134(b) and 483.136(b) of OBRA '87. The Level II Evaluation protocols that have been developed for the Missouri PASRR Program are designed to accomplish the following four objectives: 1. Provide information that will confirm or reject the presence of a serious mental illness (SMI), intellectual disability/developmental disability (ID/DD) or Related Condition (RC) as defined by PASRR; 2. Document an individual's current functional level and medical conditions to support a level of service recommendation; 3. Determine an individual's current strengths and weaknesses as the basis for a determination of the need for specialized services or services of a lesser intensity; and 4. Serve as a clinically sound base of information for care planning team in the development of effective, individualized treatment.

The Level II evaluation process includes the determination if an individual seeking admission to a Medicaid-certified nursing facility: 1. Meets the state/federal criteria for serious mental illness, intellectual disability, developmental disability, and/or related condition; and 2. Requires specialized psychiatric services, specialized developmental disability services, or rehabilitative services of a lesser intensity that may be provided by a nursing facility.

(ii) Level of impairment. The disorder results in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the individual's developmental stage. An individual typically has at least one of the following characteristics on a continuing or intermittent basis:

A. Interpersonal functioning. The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships and social isolation; B. Concentration, persistence and pace. The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks; and C. Adaptation to Change. The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system.

Serious mental illness (SMI) - as outlined in section 483.102(b)(1) of CMS's final rule for PASRR, an individual is considered to have a serious mental illness (SMI) if they meet the following requirements on diagnosis, level of impairment and duration of illness: (i) Diagnosis. The individual has a major mental disorder diagnosable

under the Diagnostic and Statistical Manual of Mental Disorders, (DSM- V). This mental disorder is:

A. A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; B. Not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined in paragraph (b)(1)(i)(A) of this section.

(iii) Recent treatment. The treatment history indicates that the individual has experienced Psychiatric treatment more intensive than outpatient care more than once in the past two years (e.g., partial hospitalization, crisis stabilization, non-routine psychiatric consultation, or inpatient hospitalization);

Missouri describes specialized services, in conjunction with the federal definition, as intensive mental health services provided in response to acute psychiatric episodes which result in the likelihood of serious harm to the client or others, or inability to remain in the community due to severe functional impairment.

Service intensity requires aggressive provision of specific therapies and treatment supervised by qualified mental health personnel, most often on a round-the-clock basis.

An individualized service plan must be developed and supervised by an interdisciplinary team which includes a physician, qualified mental health professional, and other professionals as appropriate. (i.e. inpatient hospitalization)

The following rehabilitative services are included within the scope of services a nursing facility must provide and incorporate into the individual’s plan of care to assist the individual in maintaining or achieving as much independence and self-determination as possible. These services of lesser frequency or intensity are to be implemented by all levels of NF staff who come in contact with the resident who is MI. Services include: Implementation of systematic plans to change inappropriate

behavior, medication therapy/monitoring to change inappropriate behavior

or alter manifestations of psychiatric illness, provision of a structured environment, implementation of ADL programs to increase independence and

self-determination, crises intervention services, development of personal support networks.

Intellectual Disability - An individual is considered to have an intellectual disability (ID) if he or she has a condition that results in significantly sub-average general intellectual functioning that originated before age eighteen (18) and that is associated with significant impairment in adaptive behavior.

A level of disability (mild, moderate, severe or profound) described in the American Association on Intellectual and Developmental Disability Mental “Intellectual Disability: Definition, Classification, and Systems of Support” (11th Edition).

Related Condition – Persons who have a related condition have a severe, chronic disability that meet all of the following conditions: 1) It is attributable to cerebral palsy or epilepsy; or any other condition, other than mental illness, found to be closely related to an intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of intellectually disabled persons, and requires treatment or services similar to those required for these person; 2) it is manifested before the person reaches age 22; 3) it is likely to continue indefinitely; 4) it results in substantial functional limitations in three or more of the following areas of major life activity: Self care, understanding and use of language, learning, mobility, self-direction, or capacity for independent living.

A continuous program which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services that is directed toward acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal functional status.

These services are typically more “intense” that the level of service a nursing facility can provide.

Specialized services do not include services to maintain generally independent individuals who are able to function with little supervision or in the absence of a continuous specialized services program.

Specialized services do not include services within the scope of services the nursing facility must provide or arrange for its residents under 1919(b)(4).

The following rehabilitative services are included within the scope of services a nursing facility must provide and incorporate into the individual’s plan of care to assist the individual in maintaining or achieving as much independence and self-determination as possible. These services of lesser frequency or intensity are to be implemented by all levels of NF staff who come in contact with the resident who is ID/ RC. Nursing and related services; specialized rehabilitative services (physical therapy, speech-language

pathology, occupational therapy) crisis intervention, individual, group and family psychotherapy, drug therapy and monitoring of drug therapy, training in drug therapy

management, structured socialization activities to diminish tendencies toward isolation and

withdrawal,

development and maintenance of necessary daily living skills including grooming, personal hygiene, nutrition, health and mental health education, money management, and maintenance of the living environment,

development of appropriate personal support networks,

Physician services; Medically related social services; Pharmaceutical services; Dietary services; Activities program; and Dental services.

Less than 21 points in Level I Determination that an individual presents an

imminent risk to self or others in Level I (suicidal, homicidal)

Needs specialized services for MI (Level II) Needs specialized services for ID/DD/RC (Level II) ID/DD/RC determination that NF is not the least

restrictive and most appropriate setting and viable community alternatives are available and desired by the individual, legal guardian, etc. (Level II)

http://www.pasrr.org

https://www.cms.gov/pasrr/

http://www.pasrrassist.org/

Please see the online PASRR training located on the DHSS website

http://health.mo.gov//seniors/nursinghomes/pasrr.php Three ways to submit the DA 124 application to COMRU:

1. Encrypted Email to comru@health.mo.gov (Put a READ receipt to know when COMRU opens your email) 2. Overnight mail: 3418 Knipp Drive, Suite F Jefferson City, MO 65109 3. Regular mail: P.O. Box 570 Jefferson City, MO 65102

Level II/Special Admission Category Questions: Brenda King 573-526-8592 Ammanda Ott 573-526-3632 Regular Applications Questions: Carrie Montgomery 573-526-8609 Sally Stockman 573-526-7828

Kathy Schafer, BA, CDDN Registered Nurse Clinical Operations Department of Mental Health 1706 East Elm, Jefferson City, MO 65102 Phone: 573-751-8070 Fax: 573-751-8346 E-mail: Kathy.Schafer@dmh.mo.gov Website: www.dmh.mo.gov Follow us on Facebook: facebook.com\MentalHealthMO Follow us on Twitter: @MentalHealthMO