PASRR M A R K F R A N C I S , M S , L N H A LT C L E A D E R S H - - PowerPoint PPT Presentation
PASRR M A R K F R A N C I S , M S , L N H A LT C L E A D E R S H I P C O A C H M U M D S A N D Q U A L I T Y R E S E A R C H T E A M S I N C L A I R S C H O O L O F N U R S I N G U N I V E R S I T Y O F M I S S O U R I C O L U M B
M A R K F R A N C I S , M S , L N H A LT C L E A D E R S H I P C O A C H M U M D S A N D Q U A L I T Y R E S E A R C H T E A M S I N C L A I R S C H O O L O F N U R S I N G U N I V E R S I T Y O F M I S S O U R I C O L U M B I A
Medicaid were required to “provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care”.
established a bill of rights for nursing home residents.
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Services (CMS) issued updated federal nursing home regulations. This was the first comprehensive revision to the regulations since they were issued in 1991 despite significant changes in the industry.
implemented in three phases: Phase 1- November 28, 2016; Phase 2
The Department of Health and Senior Services (DHSS) utilizes the Initial Assessment-Social and Medical forms (DA124 A/B) to initiate the process for admission to a Nursing Facility. DHSS determines the need for nursing facility services through established NF level of care criteria (24 points). The Medicaid level of care criteria can be found in DHSS regulation 19 CSR 30-81.030 PDF Document. A special admission category must be granted/approved by DHSS to admit an individual to a SNF before a PASRR assessment is completed.
admissions and existing residents.)
related condition.
This Photo by Unknown Author is licensed under CC BY-SA
D E B B I E P O O L , B S N , R N , L N H A C L I N I C A L E D U C ATO R M U M D S A N D Q U A L I T Y R E S E A R C H T E A M S I N C L A I R S C H O O L O F N U R S I N G U N I V E R S I T Y O F M I S S O U R I C O L U M B I A
ANY RESIDENT ADMITTED TO A MEDICAID CERTIFIED BED MUST COMPLETE A DA124 C (LEVEL 1) APPLICATION THIS INCLUDES DUALLY CERTIFIED BEDS, BOTH MEDICARE AND MEDICAID
(indicate re-applying for Medicaid on the DA-124 A/B);
per the MDS 3.0, indicate the Change of Status on the DA-124 A/B.
The DA-124 application will assist in identifying a resident that requires a Level II screening. The DA-124C form must be completed prior to admitting the resident to a SNF to ensure the resident doesn’t trigger a Level II screening. A Level II screening refers to a resident with a diagnosis of Mental Illness or Mental
the determination of the Level II. Triggers: Anyone admitted to a Medicaid certified bed meeting one of the following criteria:
1) Has had inpatient psychiatric treatment in the past 2 years; should have a Major Mental Illness diagnosis. 2) Indication of being dangerous to self and others; serious behavioral problems; suicidal or homicidal, even if Dementia is the primary psych diagnosis; 3) Legal Issues; incarceration or history of, charges of assault, murder, sex offence; etc. 4) Has a diagnosis of Intellectual Disability (diagnosed before age 18); 5) Has a Developmental Disability (DD) condition related to Intellectual Disability (onset before age 22). Examples: TBI, Cerebral Palsy, seizure disorder, etc.
Medicaid, the DA-124C is placed in the resident’s medical record until the resident requires a Level II screening and/or applies for Medicaid reimbursement.
Illness(MI) or Mental Retardation (MR)/developmental disability, the State of Missouri mandates a DA-124 A/B and C application be submitted to COMRU.
whether a Level II screening by DMH is required (Federal Regulation). This should be done prior to nursing facility admission unless a valid special admission category is determined.
SUBMITTIN SUBMITTING G YO YOUR APPLIC APPLICATION TION Scan and send by e ncryp te d email to COMRU@health.mo.gov Ove rni ght mai l DHSS/COMRU 3418 Knipp Drive, Suite F Jefferson City, MO 65109 Re gul ar Mai l DHSS/COMRU PO Box 570 Jefferson City, MO 65102
If the application is emailed, DO NOT send the application via mail. Do not fax the application unless instructed.
Section A Identifying Information/ Resident Demographics Submitting facility with contact information
Guidance
S ECTI ON D. S PECI AL ADM I SSI ON C ATEGORI ES ( TO B E USED ONLY W HEN LEVEL I I S CREENI NG I NDI CATED)
SPECIAL SPECIAL ADMISSION ADMISSION CATEGOR TEGORY Y (S (SAC)
Used only when the application triggers the Level II Must be validated by COMRU Time specific, facility is responsible for notifying COMRU of discharge or to start the Level II process
SA SAC REFER REFERRAL AL SHEE SHEET
Section D of DA-124C should correspond to the SAC Referral Sheet. It is the admitting facility’s responsibility to ensure completion and accuracy.
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Facility (SNF) prior to completion of a Level II PASRR evaluation or Special Admission Category.
paperwork) will send the completed DA 124 C form to the SNF prior to discharge. The SNF should review the client’s information to ensure the Level of Care points (24) would meet prior to admission and ensure they have enough information to determine if they can meet the medical and behavioral needs of the individual.
(DA 124 A/B, DA 124 C and any other supporting documentation) with a Special Admission Category form indicating “Waiver due to COVID 19” to COMRU@health.mo.gov
Effective April 2, 2020 and through the end of the Federal Emergency Declaration, certified Skilled Nursing Facilities and Intermediate Care Facilities may follow the process outlined below for new admissions into Medicaid- certified beds. For an applicant that may require a Level II evaluation (have a qualifying mental illness (MI) or intellectual disability (ID) diagnosis)
11 1135 WAIVER
reside at the SNF after 30 days.
complete DA 124 application to COMRU within 14 days of admission to the SNF.
applicant meets Level of Care and refer applicants requiring a Level II PASRR screening to DMH.
(MI) or intellectual disability (ID) will receive a Resident Review as soon as resources become available.
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Facility (SNF) prior to completion of a Level II PASRR evaluation or Special Admission Category.
applications as Special Admission Category #5 indicating “Waiver due to COVID -19”.
will notify COMRU via email of the following information: the client’s name, DCN or SSN#, and the receiving SNF information (Name, Telephone number and fax number).
DA 124 application (DA 124 A/B form and DA 124 C form) are sent to the accepting SNF prior to discharge.
For completed applications already submitted to COMRU for processing.
This information should be added to the DA 124 application in process and sent to DMH. For the DA 124 applications that were already referred for Level II PASRR screening, DHSS will notify DMH and Bock & Associates via email of the individuals change in location.
S E C T I O N F S E C T I O N F. P H Y P H YS I C I A N S I C I A N AU T H O R I Z A U T H O R I Z AT I O N I O N / S I G N / S I G NAT U T UR E R E Physician discipline, license number and date of signature required. Print physician’s full name under signature. NP/PA CANNOT sign the form.
DA DA - 12 4 A A / B
Section A. Social assessment. Resident demographics. Contact person. Guidance for completion on reverse side.
DA DA - 12 4 A A / B
Guidance
S E C T I O N B . S E C T I O N B . M E D I C M E D I CAL L A S S E S S M E N T A S S E S S M E N T
#6. Recent medical events: surgery, CVA, fracture, head injury with dates. #8. Prescription meds: dosage and frequency, must correspond to a medical
124 application or MAR. Include on a second page is necessary. #15 Indicate if able to negotiate pathway to safety.
S E C T I O N B . S E C T I O N B . # 1 # 16 . 6 . A S S E S S E D A S S E S S E D N E E D S N E E D S
Points are assigned for the amount
the level of care criteria. The resident is assessed and if determined to have a point level of 24 or more can be admitted to the SNF. Points come from mobility, dietary, restorative services, monitoring, medications, behaviors, treatments, personal care and rehab services.
mental, #14 Behavioral information and #15 Functional impairments
– resident requires physical therapy 5x weekly – resident needs assistance with dressing and is incontinent
complete with inclusion of all relevant information to resident care.
to complete the application and release to Family Support Division.
correspondence to be sent to the facility or hospital from COMRU.
to another SNF.
must be obtained from the prior SNF for the current medical record.
surveyors.
are included on the admission/baseline care plan.
in Status. The resident must have been approved for SNF placement and has not been out of the SNF for greater than 60 days.
3.0 regarding a resident’s needs. It can either be a decline or improvement and can be a physical or mental change.
– Refer to RAI manual Chapter 2 pgs. 22-29 for SCSA requirements.
diagnosis of MI or MR ( not all residents).
the resident triggered a Significant Change in Status (what were the triggers on the MDS 3.0).
Status.
facility would need to complete and submit the DA-124 application for review.
applications, instructions, PDF documents
Assessments A0310A-04, pages 22-29
Clinical Educator
Critical Element Pathway Form CMS-20090 (5/2017)
Tracy Niekamp, Assistant Administrator Section for Long‐Term Care Regulation
First Step‐ Level of Care Assessment and 19 CSR 30‐81.030(5)(G)(6)
exhibits uncontrolled behavior that is dangerous to themselves or others.
extensive supervision due to psychological, developmental disabilities or traumatic brain injuries with resultant confusion, incompetency, hyperactivity, hostility, severe depression, or
bizarre behavior, are verbally or physically abusive, or both, or are incapable of self‐direction.
themselves or others “must be transferred immediately to an appropriate facility”.
Second Step‐ Pre‐Admission Screening and Resident Review (PASRR)
diagnoses that include a mental disorder and/or an intellectual disability. (DA 124 C)
to the Department of Mental Health (DMH).
(suspect to have mental disorder or an intellectual disability), they contact Bock and Associates (DMH contractor) to conduct a PASRR‐Level II assessment. A nursing facility will not receive Medicaid payment for individuals until approval has been determined by DMH.
Assessments are completed a report is compiled that discusses the following:
“Specialized Services” and “Lesser Intensity Service Needs” are services or supports that a resident requires due to mental illness, intellectual disability or related condition that supplements the typical scope of services that the nursing facility provides.
to appropriate community resources
F646 – Prompt Notification after a Significant Change A nursing facility must notify the Department of Mental Health, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review. Intent‐ To ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status
“Significant Change” is a major decline or improvement in a resident’s status that 1) will not normally resolve itself without intervention by staff
implementing standard disease‐related clinical interventions; the decline is not considered “self‐limiting” (NOTE: Self‐limiting is when the condition will normally resolve itself without further intervention
interventions to resolve the condition.); 2) impacts more than one area of the resident’s health status; and 3) requires interdisciplinary review and/or revision of the care plan. Reference: F646
A significant change for purposes of PASRR may or may not trigger a significant change in condition in the RAI/MDS process. The nursing facility must notify DMH of significant changes in residents with MD or ID independent
PASARR/Level II is to function as an independent assessment process for this population with special needs, in parallel with the facility’s assessment process. Referral to DMH should be made as soon as the criteria indicative of a significant change are evident — the facility should not wait until the significant change in condition assessment is complete. Reference: F646
Examples of such changes include, but are not limited to:
placement recommendations may require modifications.
symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living.
resident’s most recent PASARR Level II evaluation and determination. (NOTE that a referral for a possible new Level II PASARR evaluation is required whenever such a disparity is discovered, whether or not associated with a SCSA.)
Reference: F646
To notify DMH of a change in status related to disability or mental illness, providers can access the Notification to DMH for CIS and Resident Review Referral Form on DMH’s webpage: https://dmh.mo.gov/dev‐disabilities/programs/pasrr‐level‐ii‐assessments
the criteria for reporting the change to DMH.
behaviors?
evaluation differs from the individual’s current condition. The referral form should be emailed to: DMHNotifications@dmh.mo.gov. Reference: F646
Baseline Care Plan‐ F655 Baseline care plan must include the minimum information necessary to properly care for each resident immediately upon their admission. It should address resident‐specific health and safety concerns to prevent decline or injury, such as elopement or fall risk, and identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. Baseline care plans are required to address, at a minimum, the following:
Reference: F655
Comprehensive care plan‐ F656 Consistent with the resident rights, includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If the interdisciplinary team disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record, including an explanation of why the resident’s current assessed needs are inconsistent with the PASARR recommendations and how the resident would benefit from alternative interventions. The facility should also document a resident’s preference for a different approach to achieve goals or refusal of recommended services.
Comprehensive Care Plans‐F658 The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— ‐ Meet professional standards of quality.
Comprehensive Care Plans‐ F659 The services provided or arranged by the facility, as outlined by the comprehensive care plan, must— ‐ Be provided by qualified persons in accordance with each resident’s written plan of care. (Do they have the skills, experience, and knowledge to provide care and services that meet the resident’s needs?) ‐ Be culturally‐competent and trauma–informed. (Are staff informed of past trauma or post traumatic stress that impacts the resident and how they interact in particular situations)
Behavioral Health Services‐ F740 Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well‐being, in accordance with the comprehensive assessment and plan of care.
autonomy, privacy, socialization, independence, choice, and safety;
well‐being.
between residents and staff, families, other residents and the community.
ineffective or when clinically indicated.
Behavioral and Emotional Status Critical Element Pathway (CMS‐20067)
residents;
health care needs, identified in the comprehensive assessment;
residents have access to community substance use services);
resident has a change in condition;
and interventions;
developed by the IDT to support each resident; or
progression of the resident’s diagnosed condition.
Sufficient staff with appropriate competencies and skills to assure resident safety and highest practicable well‐being. (F740) Competencies and skill sets include knowledge of and appropriate training and supervision for:
trauma and/or post traumatic stress disorder
Behavioral Health Services‐F742 The facility must ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post‐traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well‐being. Residents with a mental or psychosocial adjustment difficulty, or who have a history of trauma and/or PTSD, must receive appropriate person‐centered and individualized treatment and services to meet their assessed needs.
Deficient practice at F742, will generally show that the facility failed to:
the scope of the resources in the facility assessment;
emotional and psychosocial needs of the resident; or
and accurately document all actions in the medical record.
Citations at F742 and F646 can be intertwined If expressions or indications of distress, lack of improvement or decline in resident functioning are identified by the facility‐ they should be documented in the resident’s record and steps taken to determine the underlying cause of the negative outcome. (F742) In these instances, a significant change notification should be made by the facility to DMH for a determination of whether or not a PASRR – Level II reevaluation needs to be completed at directed in F646.
Resident to Resident Altercation Considerations
Emergency Discharges
Discharges
reassessment for moving to less restrictive living situation.
PASRR Technical Assistance https://www.pasrrassist.org Partnering for Quality for Care: State PASRR Authorities and Nursing Facilities‐ FREE webinar recording 1.5 hours
Tracy Niekamp Assistant Section Administrator Tracy.Niekamp@health.mo.gov Molly Miller, RN Health Program Coordinator Molly.Miller@health.mo.gov