(a) The
Department of Health and Senior Services is the agency responsible for
administering the Preadmission Screening Program. The following is provided to
hospitals so that they understand the process and the rules a hospital shall
follow to ensure Medicaid or NJ FamilyCare-Plan A reimbursement for the care of
individuals whose discharge planning includes placement into a nursing
facility.
(b) The following words
and terms, when used in this section, shall have the following meanings, unless
the context clearly indicates otherwise.
"Health Services Delivery Plan (HSDP)" means an initial plan
of care prepared during the Preadmission Screening (PAS) process. The HSDP
reflects the individual's current or potential problems, required care needs,
the need for Preadmission Screening and Resident Review (PASRR) and the Track
of Care.
"Level I PASRR screen" means the process of identification of
an individual meeting the criteria for serious mental illness (MI) or mental
retardation (MR) or both, as described throughout this section, and determining
whether the individual also meets the NF level of care requirements.
"Level II PASRR evaluation" means the process of evaluating
and determining whether an individual meets NF level of care, and determining
whether an individual needs specialized services for MI or MR or both. An
individual who requires specialized services cannot receive those services in a
NF.
"Preadmission screening (PAS)" means that process by which
all Medicaid eligible beneficiaries seeking admission to a Medicaid certified
NF and individuals who may become Medicaid eligible within six months following
admission to a Medicaid certified NF, receive a comprehensive needs assessment
by professional staff designated by the Department of Health and Senior
Services to determine their long-term care needs and the most appropriate
setting for those needs to be met, pursuant to
N.J.S.A.
30:4D-17.10. ( P.L. 1988, c.97.)
"Preadmission Screening and Resident Review (PASRR)" means
that process by which all individuals meeting the clinical criteria for mental
illness (MI) or mental retardation (MR), regardless of payment source, are
screened prior to admission to an NF in order to determine the individual's
appropriateness for NF services, and whether the individual requires
specialized services for his or her condition. PASRR includes two levels, Level
I PASRR screen and Level II PASRR evaluation, as defined above and described in
this section.
"Professional staff designated by the Department of Health
and Senior Services (DHSS professional staff)" means a nurse licensed or
certified in accordance with N.J.A.C. 13:37 or a social worker who performs
health needs assessments and care management counseling in accordance with this
section.
"Specialized Services for Mental Illness (MI)" means those
services that are determined to be medically indicated when an individual is
experiencing an acute episode of serious mental illness and psychiatric
hospitalization is recommended, based upon a Psychiatric Evaluation.
Specialized Services entail implementation of a continuous, aggressive and
individualized treatment plan by an interdisciplinary team of qualified and
trained mental health personnel. During a period of 24-hour supervision of the
individual, specific therapies and activities are prescribed, with the
following objectives: to diagnose and reduce behavioral symptoms; to improve
independent functioning; and as early as possible, to permit functioning at a
level where less than Specialized Services are appropriate. Specialized
Services go beyond the range of services that an NF is authorized to provide
and can only be provided in a 24-hour inpatient psychiatric setting.
"Specialized Services for Mental Retardation (MR)" means
those services required when an individual is determined to have skill deficits
or other specialized training needs that necessitate the availability of
trained MR personnel, 24-hours per day, to teach the individual functional
skills. Specialized Services are those services needed to address such skill
deficits or specialized training needs. Specialized services may be provided in
an Intermediate Care Facility for the Mentally Retarded (ICF/MR) or in a
community-based setting which meets ICF/MR standards. Specialized services go
beyond the range of services which a NF is authorized to provide.
"Track of care" means designation of the setting and scope of
Medicaid/NJ FamilyCare-Plan A services as determined by the PAS process. The
PAS is conducted by the professional staff designated by the Department of
Health and Senior Services (DHSS) following an assessment of the Medicaid or NJ
FamilyCare-Plan A beneficiary or potential Medicaid or NJ FamilyCare-Plan A
beneficiary, as follows:
1. "Track I"
means long-term NF care;
2. "Track
II" means short-term NF care; and
3. "Track III" means long-term care services
in a community setting.
(c) Preadmission screening (PAS)
authorization shall be required prior to admission to a Medicaid certified NF
of a Medicaid or NJ FamilyCare-Plan A beneficiary, or an individual who may
become a Medicaid or NJ FamilyCare-Plan A beneficiary within six months
following placement in a Medicaid certified NF. If the NF applicant has
received psychiatric inpatient care for a year or more, a PASRR shall be
performed, in addition to the PAS, prior to admission. Professional staff
designated by DHSS shall assess each individual's care needs and determine the
appropriate setting for the delivery of needed services. Professional staff
designated by DHSS will authorize or deny NF placement based on the clinical
eligibility requirements at
N.J.A.C.
8:85-2.1 and the feasibility of alternative
placement and will designate the track of care, in accordance with
N.J.A.C.
8:85-1.8.
(d) PAS authorization is also required for
individuals identified as having a serious MI or MR regardless of the payment
source. The PASRR assessment and authorization process shall be subsumed within
the State's PAS protocols, as required by (e) below.
1. A Level I PASRR screen shall be required
for individuals suspected of, or diagnosed as having serious MI, MR, or both or
related conditions.
2. An
individual is considered to have a serious mental illness (MI) if he or she has
a mental illness, such as schizophrenia, mood disorder, paranoia, panic or
severe anxiety disorder, or similar condition found in the Diagnostic and
Statistical Manual of Mental Disorders (DSM IV-TR 2000 edition) (available from
the American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825,
Arlington, VA 22269-3901 and
www.psych.org) that leads to a chronic
disability and that meets the PASRR requirements for diagnosis, level of
impairment and duration of illness.
i. An
individual is considered to have dementia if he or she has a primary diagnosis
of dementia, as described in the Diagnostic and Statistical Manual of Mental
Disorders (DSM IV-TR 2000 edition) and does not have a serious mental
illness.
3. An
individual is considered to have mental retardation (MR) if he or she has a
level of retardation (mild, moderate, severe or profound) described in the
"American Association on Mental Retardation's Manual on Classification in
Mental Retardation (1983)" or a related condition, as defined by, and pursuant
to, Section 1905(d) of the Social Security Act (Omnibus Budget Reconciliation
Act of 1987 P.L. 100-203);
42 U.S.C. §
1396(d), and (d)3i below. An
individual with a diagnosis of MR or a related condition and a diagnosis of
dementia shall receive a Level II PASRR screen prior to admission to a Medicaid
certified nursing facility.
i. "Persons with
related conditions" means individuals who have a severe and chronic disability
that meets all of the following conditions:
(1) The person has a diagnosis of mental
retardation (MR) or other developmental disability, such as cerebral palsy,
epilepsy, autism, spina bifida or other neurological impairment; and
(2) The person has a history or past records
which show that the onset of the mental retardation or related conditions
occurred prior to age 22.
4. A Level II PASRR evaluation shall be
conducted for mentally ill or mentally retarded individuals only if the
assessment performed by the professional staff designated by DHSS results in
authorization of NF placement.
i. A Level II
PASRR evaluation for individuals with serious MI requires that a psychiatric
examination be performed by a Board eligible/certified psychiatrist or APN
certified in mental health to determine the need for specialized services, in
accordance with (e) below. When all reasonable efforts to secure a psychiatrist
fail, an M.D. or D.O. who is not a psychiatrist may perform the
examination.
ii. A Level II PASRR
evaluation for MR individuals will be performed by the Division of
Developmental Disabilities (DDD) to determine the need for specialized
services, in accordance with (e) below.
5. Hospitals shall not transfer an individual
requiring a Level II PASRR evaluation to Medicaid-certified NFs until the Level
II PASRR has been conducted and the hospital has received a Department of
Health and Senior Services Office of Community Choice Options letter of
approval indicating that the individual does not require specialized
services.
6. For individuals
diagnosed with Alzheimer's or related dementias, documentation to support the
diagnosis, including the history, physical examination and diagnostic workup
shall be provided to the admitting Medicaid certified nursing facility for the
individual's clinical record.
7.
After an initial PASRR process has been completed, the individual transferred
from a nursing facility to an acute care general hospital or an individual with
serious MI being transferred to a psychiatric hospital for less than one year
shall not require a Level I PASRR screen or a Level II PASRR evaluation prior
to transfer back to a nursing facility. If the individual is transferred to a
different facility, the hospital discharge planner shall advise the admitting
NF of the individual's former NF placement.
(e) The determination of the necessity for NF
level of care shall be performed through Preadmission Screening (PAS), as
mandated by
N.J.S.A.
30:4D-17.10. Professional staff designated by
DHSS shall determine the necessity for NF level of care for Medicaid and NJ
FamilyCare-Plan A beneficiaries, for individuals who may become Medicaid and NJ
FamilyCare-Plan A beneficiaries within six months following admission to a
Medicaid certified facility, and for individuals identified as meeting PASRR
Level I criteria. The Office of Community Choice Options (OCCO) having
jurisdiction for the area where an acute care hospital is located has the
responsibility for completing the PAS assessment regardless of the
beneficiary's county of residence or anticipated county of discharge. A listing
of the Offices of Community Choice Options can be obtained by writing to the
Director, Division of Aging and Community Choice Options, Department of Health
and Senior Services, PO Box 807, Trenton, New Jersey 08625-0807, or by
accessing the DHSS Division of Consumer Support website at
www.state.nj.us/health/consumer/directory.htm,
or by accessing the fiscal agent website at
www.njmmis.com and clicking on the
"Frequently Asked Questions" tab.
1.
Professional staff designated by DHSS will review the medical, nursing and
social information obtained at the time of assessment, as well as any other
supporting data, in order to assess the individual's care needs and determine
the appropriate setting for the delivery of needed services. The professional
staff designated by DHSS will authorize or deny NF placement based on the
clinical eligibility requirements found at
N.J.A.C.
8:85-2.1 and the feasibility of alternative
placement. Professional staff designated by DHSS will also designate the track
of care.
i. If alternative care is available,
accessible and appropriate to the needs of the individual, the request for NF
placement will be denied.
ii. If an
appropriate alternative placement becomes available and accessible for a person
already approved for NF care and awaiting placement, the authorization for NF
placement will be rescinded.
iii.
The professional staff designated by DHSS will advise the hospital discharge
planner or social worker of the NF level of care approval and the setting for
the delivery of needed services. If the individual requires a Level II PASRR
evaluation, a letter will be given to the individual advising him or her that
the Level II PASRR evaluation must be completed prior to admission to the
NF.
2. The professional
staff designated by DHSS will schedule and perform the assessment process
within three working days of the hospital discharge planner or social worker's
initial contact with the OCCO. Individuals who exhibit unstable, severe medical
conditions, such as a patient in the Intensive Care or Coronary Care Unit or a
patient who is awaiting surgery, shall not be referred for PAS until that
condition has stabilized.
3. A
signed Release of Information form shall be obtained from the potentially
Medicaid-eligible patient. If the patient refuses NF placement, home care
services, or participation in the PAS assessment process, the professional
staff designated by DHSS will make every effort to obtain a signed
participation declination statement, which will be included in the patient's
OCCO case record.
4. NF placement
approval: The professional staff designated by DHSS will verbally advise the
hospital discharge planner or social worker and patient or legal representative
of the assessment decision.
i. For a Track I
or II determination, the professional staff designated by DHSS will leave a
copy of the HSDP and signed approval letter with the discharge planner or
social worker. For individuals requiring a Level II PASRR evaluation, the
signed approval letter and HSDP shall be forwarded only after the determination
has been made that no specialized services are required.
ii. For a Track III determination, the
professional staff designated by DHSS will leave a copy of the HSDP with the
discharge planner or social worker to forward to the home care provider. The
discharge planner or social worker shall arrange needed home health services
and forward a copy of the HSDP to the home care agency. A Track III
determination shall not be an authorization for NF services.
iii. The original approval letter signed by
the professional staff designated by DHSS will be sent by the OCCO to the
individual or his or her legal representative with copies to the county welfare
agency (CWA).
iv. A copy of the
HSDP must be attached to the hospital discharge material and forwarded with the
patient to the admitting NF.
(1) If the
patient being transferred will be eligible for Medicare benefits, the transfer
shall be made to a Medicare/Medicaid participating NF.
5. NF placement denial: The
professional staff designated by DHSS will verbally advise the hospital
discharge planner or social worker and patient or the patient's legal
representative of the assessment decision. The professional staff designated by
DHSS will leave a signed copy of the NF placement denial letter with the
discharge planner or social worker. The original denial letter, signed by the
professional staff designated by DHSS, will be sent to the patient or the
patient's legal representative by the OCCO, with copies to the county welfare
agency (CWA).
(f) The
hospital discharge planner or social work staff shall be responsible for
identifying a Medicaid or NJ FamilyCare-Plan A beneficiary inpatient or a
Medicaid or NJ FamilyCare-Plan A applicant inpatient who may be at risk of NF
placement.
1. The identification process shall
also include any inpatient in need of NF care who may become a Medicaid or NJ
FamilyCare-Plan A beneficiary within six months after NF admission, as well as
individuals meeting PASRR Level I criteria. (See
N.J.A.C.
10:52-1.9(c).) These
patients shall be referred by the hospital to the OCCO and the CWA on the basis
of the "At Risk Criteria for Nursing Facility Placement and Referral to the
OCCO for PAS Evaluation" in (g) below. Medicaid or NJ FamilyCare-Plan A
beneficiaries already residing in Medicaid participating facilities who are
transferred to an acute care hospital and who are transferred to either the
same or a different NF, shall not require PAS authorization.
i. Within one working day of identifying an
inpatient as being at risk for NF placement, the hospital discharge planner or
social worker shall:
(1) Make a telephone or
FAX referral to the OCCO and the CWA;
(2) If not already a Medicaid or NJ
FamilyCare-Plan A beneficiary, generate a Public Assistance Inquiry (PA-1C) to
initiate the application process for Medicaid or NJ FamilyCare-Plan A;
and
(3) Within two working days of
the telephone referral to the OCCO and CWA, the Hospital Discharge Planning
Office shall forward the completed "Hospital Preadmission Screening Referral
(LTC-4)" to the OCCO, unless the LTC-4 was faxed on the day of the
referral.
2.
The Level II PASRR evaluation for individuals identified as meeting the PASRR
criteria shall be completed by a Board eligible or Board certified psychiatrist
or APN certified in psychiatric/mental health:
i. The hospital discharge planning unit or
social services department shall immediately arrange through the individual's
attending physician, a consultation by a Board eligible, a Board certified
hospital staff psychiatrist or an APN certified in mental health to complete
the "PASRR Psychiatric Evaluation" (DMHS 2009) form. The "PASRR Psychiatric
Evaluation" form shall not be completed until such time as the professional
staff designated by DHSS has determined the level of care and the need for a
PASRR Level II evaluation.
ii.
Within 48 hours of completion of the PASRR Level II evaluation, the completed
"PASRR Psychiatric Evaluation" form shall be faxed to (609) 777-0662 or mailed
to the Division of Mental Health Services, PO Box 727, Trenton, New Jersey
08625-0727, Attention: PASRR Coordinator.
(1)
A copy of the "PASRR Psychiatric Evaluation" form may be requested from the
PASRR Coordinator in the Division of Mental Health Services.
iii. The OCCO shall contact the
appropriate Regional Office of the Division of Developmental Disabilities (DDD)
agency to advise them of the need for a Level II PASRR evaluation. The Level II
PASRR evaluation will be completed by the DDD staff within three working days
of the OCCO contact.
iv. DMHS or
DDD shall notify the OCCO of the determination of need for specialized services
who, in turn, shall provide the hospital discharge planning unit or social
services department with the approval or denial decision for placement in a
Medicaid-certified NF.
(g) The following "At-Risk Criteria for
Nursing Facility Placement and Referral to the OCCO for PAS" shall be utilized
by the hospital in determining if a referral for long-term care services,
either in an NF or in the community, is indicated:
1. The medical criteria are as follows. Has
the patient experienced any of the following:
i. Catastrophic illness requiring major
changes in lifestyle or living conditions, such as, multiple sclerosis, stroke,
multiple trauma, AIDS, amputation, neurological disease, cancer, birth
defect(s), or end stage renal disease;
ii. Debilitation or chronic illness causing
progressive deterioration of self-care skills, such as, severe chronic disease,
spina bifida, progressive pulmonary disease or diabetes;
iii. Multiple hospital admissions within the
past six months not including patients admitted directly from NFs;
iv. Previous NF admissions within the past
two years; or
v. Major health
needs, that is, tube feedings, special equipment or treatments,
rehabilitation/restorative services.
2. The social criteria are as follows: In
addition to the medical criteria, does the patient meet any of the following
social situations:
i. Homeless;
ii. Lives alone and/or has no immediate
support system;
iii. Primary
caregiver is not able to provide required care services; or
iv. Lack of adequate support
systems.
3. The
financial criteria are as follows. Does the patient meet any of the income and
asset tests:
i. Currently eligible for
Medicaid or NJ FamilyCare-Plan A;
ii. Monthly income at/or below the current
institutional level specified at
N.J.A.C.
10:71-5.6.
(1) Has no spouse in the community and
resources no greater than those specified at
N.J.A.C.
10:71-4.4 and 4.5;
(2) Has no spouse in the community and has
resources at or below the maximum amount allowable, as determined by the
Centers for Medicare & Medicaid Services (CMS) in accordance with the
Medicare Catastrophic Coverage Act of 1988 (see N.J.A.C. 10:71). (This is an
indication that the patient may become Medicaid or NJ FamilyCare-Plan A
eligible within the next six months by spending down assets in an NF as private
pay); or
(3) Has a spouse in the
community with combined countable resources at or below the maximum amount
allowable, as determined by CMS in accordance with the Medicare Catastrophic
Coverage Act of 1988 (see N.J.A.C. 10:71).
iii. Monthly income at or below the current
New Jersey Care . . . Special Medicaid programs maximum monthly income limit
specified at
N.J.A.C.
10:72-4.1 and:
(1) Has no spouse in the community and
resources no greater than those specified at
N.J.A.C.
10:71-4.4 and 4.5;
(2) Has no spouse in the community and
resources at or below the maximum amount allowable, as determined by CMS in
accordance with the Medicare Catastrophic Coverage Act of 1988 (see N.J.A.C.
10:71). This is an indication that the patient may become Medicaid or NJ
FamilyCare-Plan A eligible within the next six months by spending down assets
in an NF as private pay; or
(3) Has
a spouse in the community with combined countable resources at or below the
maximum amount allowable, as determined by CMS in accordance with the Medicare
Catastrophic Coverage Act of 1988 (see N.J.A.C. 10:71).
(h) The hospital
discharge planner or social worker shall be responsible for the discharge or
placement arrangements of the patient.
1. For
each hospital patient referred for PAS, the hospital shall complete and send to
the OCCO a "Hospital Preadmission Screening Discharge form (LTC-8)."
i. For any patient discharged to a NF, a
Discharge Package (HSDP, discharge paper work, DHSS approval letter, hospital
transfer sheet and PASRR documentation, including any documentation which
supports a diagnosis of Alzheimer's disease or related organic dementia) shall
be compiled to accompany the patient to the NF.
(1) If the patient being transferred to a NF
is eligible for Medicare benefits, the transfer shall be made to a
Medicare/Medicaid participating NF.
ii. For those beneficiaries discharged to
community locations, the hospital social worker or discharge planner shall be
responsible for the implementation of the HSDP by securing home care
services.
