specialized services
(7) State requirements for preadmission screening and resident review (A) Preadmission screening (i) In general Effective January 1, 1989 , the State must have in effect a preadmission screening program, for making determinations (using any criteria developed under subsection (f)(8)) described in subsection (b)(3)(F) for mentally ill and mentally retarded individuals (as defined in subparagraph (G)) who are admitted to nursing facilities on or after January 1, 1989 . The failure of the Secretary to develop minimum criteria under subsection (f)(8) shall not relieve any State of its responsibility to have a preadmission screening program under this subparagraph or to perform resident reviews under subparagraph (B). (ii) Clarification with respect to certain readmissions The preadmission screening program under clause (i) need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (iii) Exception for certain hospital discharges The preadmission screening program under clause (i) shall not apply to the admission to a nursing facility of an individual— (I) who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (II) who requires nursing facility services for the condition for which the individual received care in the hospital, and (III) 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. (B) State requirement for resident review (i) For mentally ill residents As of April 1, 1990 , in the case of each resident of a nursing facility who is mentally ill, the State mental health authority must review and determine (using any criteria developed under subsection (f)(8) and based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority)— (I) whether or not the resident, because of the resident’s physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an inpatient psychiatric hospital for individuals under age 21 (as described in section 1396d(h) of this title ) or of an institution for mental diseases providing medical assistance to individuals 65 years of age or older; and (II) whether or not the resident requires specialized services for mental illness. (ii) For mentally retarded residents As of April 1, 1990 , in the case of each resident of a nursing facility who is mentally retarded, the State mental retardation or developmental disability authority must review and determine (using any criteria developed under subsection (f)(8))— (I) whether or not the resident, because of the resident’s physical and mental condition, requires the level of services provided by a nursing facility or requires the level of services of an intermediate care facility described under section 1396d(d) of this title ; and (II) whether or not the resident requires specialized services for mental retardation. (iii) Review required upon change in resident’s condition A review and determination under clause (i) or (ii) must be conducted promptly after a nursing facility has notified the State mental health authority or State mental retardation or developmental disability authority, as applicable, under subsection (b)(3)(E) with respect to a mentally ill or mentally retarded resident, that there has been a significant change in the resident’s physical or mental condition. (iv) Prohibition of delegation A State mental health authority, a State mental retardation or developmental disability authority, and a State may not delegate (by subcontract or otherwise) their responsibilities under this subparagraph to a nursing facility (or to an entity that has a direct or indirect affiliation or relationship with such a facility). (C) Response to preadmission screening and resident review As of April 1, 1990 , the State must meet the following requirements: (i) Long-term residents not requiring nursing facility services, but requiring specialized services In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require specialized services for mental illness or mental retardation, and who has continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident’s family or legal representative and care-givers— (I) inform the resident of the institutional and noninstitutional alternatives covered under the State plan for the resident, (II) offer the resident the choice of remaining in the facility or of receiving covered services in an alternative appropriate institutional or noninstitutional setting, (III) clarify the effect on eligibility for services under the State plan if the resident chooses to leave the facility (including its effect on readmission to the facility), and (IV) regardless of the resident’s choice, provide for (or arrange for the provision of) such specialized services for the mental illness or mental retardation. A State shall not be denied payment under this subchapter for nursing facility services for a resident described in this clause because the resident does not require the level of services provided by such a facility, if the resident chooses to remain in such a facility. (ii) Other residents not requiring nursing facility services, but requiring specialized services In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility, but to require specialized services for mental illness or mental retardation, and who has not continuously resided in a nursing facility for at least 30 months before the date of the determination, the State must, in consultation with the resident’s family or legal representative and care-givers— (I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2), (II) prepare and orient the resident for such discharge, and (III) provide for (or arrange for the provision of) such specialized services for the mental illness or mental retardation. (iii) Residents not requiring nursing facility services and not requiring specialized services In the case of a resident who is determined, under subparagraph (B), not to require the level of services provided by a nursing facility and not to require specialized services for mental illness or mental retardation, the State must— (I) arrange for the safe and orderly discharge of the resident from the facility, consistent with the requirements of subsection (c)(2), and (II) prepare and orient the resident for such discharge. (iv) Annual report Each State shall report to the Secretary annually concerning the number and disposition of residents described in each of clauses (ii) and (iii). (D) Denial of payment (i) For failure to conduct preadmission screening or review No payment may be made under section 1396b(a) of this title with respect to nursing facility services furnished to an individual for whom a determination is required under subsection (b)(3)(F) or subparagraph (B) but for whom the determination is not made. (ii) For certain residents not requiring nursing facility level of services No payment may be made under section 1396b(a) of this title with respect to nursing facility services furnished to an individual (other than an individual described in subparagraph (C)(i)) who does not require the level of services provided by a nursing facility. (E) Permitting alternative disposition plans With respect to residents of a nursing facility who are mentally retarded or mentally ill and who are determined under subparagraph (B) not to require the level of services of such a facility, but who require specialized services for mental illness or mental retardation, a State and the nursing facility shall be considered to be in compliance with the requirements of subparagraphs (A) through (C) of this paragraph if, before April 1, 1989 , the State and the Secretary have entered into an agreement relating to the disposition of such residents of the facility and the State is in compliance with such agreement. Such an agreement may provide for the disposition of the residents after the date specified in subparagraph (C). The State may revise such an agreement, subject to the approval of the Secretary, before October 1, 1991 , but only if, under the revised agreement, all residents subject to the agreement who do not require the level of services of such a facility are discharged from the facility by not later than April 1, 1994 . (F) Appeals procedures Each State, as a condition of approval of its plan under this subchapter, effective January 1, 1989 , must have in effect an appeals process for individuals adversely affected by determinations under subparagraph (A) or (B). (G) Definitions In this paragraph and in subsection (b)(3)(F): (i) An individual is considered to be “mentally ill” if the individual has a serious mental illness (as defined by the Secretary in consultation with the National Institute of Mental Health) and does not have a primary diagnosis of dementia (including Alzheimer’s disease or a related disorder) or a diagnosis (other than a primary diagnosis) of dementia and a primary diagnosis that is not a serious mental illness. (ii) An individual is considered to be “mentally retarded” if the individual is mentally retarded or a person with a related condition (as described in section 1396d(d) of this title ). (iii) The term “specialized services” has the meaning given such term by the Secretary in regulations, but does not include, in the case of a resident of a nursing facility, services within the scope of services which the facility must provide or arrange for its residents under subsection (b)(4).