55 Pa. Code § 1181.542 - Who is required to be screened
(a) OBRA-87 requires only that individuals
who are mentally ill or mentally retarded, including persons with other related
conditions, as defined by the law, be screened prior to admission. This
requirement applies to all those individuals, whether or not the individual is
eligible or applying for MA or Medicare benefits. However, this requirement
does not displace the existing preadmission assessment requirements for persons
eligible or applying for MA-for example, LAMP. This subchapter deals with the
OBRA-87 requirement, which is in addition to existing preadmission screening
requirements.
(b) OBRA-87 applies
only to persons seeking admission to nursing facilities, but it does not apply
to persons seeking admission to intermediate care facilities for the mentally
retarded (ICF/MR). It also does not apply to persons seeking admission to
inpatient psychiatric facilities, institutions for mental diseases, community
placement or nursing facilities which are not providers participating in the MA
Program or the Medicare Program.
(1)
Who is mentally ill as defined by OBRA-87.
(i) OBRA-87 defines an individual who is
mentally ill and therefore subject to screening as an individual who has a
primary or secondary diagnosis of mental illness-as defined in the Diagnostic
and Statistical Manual of Mental Disorders, 3rd edition-but does not have a
primary diagnosis of dementia, including Alzheimer's disease or a related
disorder. Thus, an individual who does have a primary diagnosis of dementia,
including Alzheimer's disease or a related disorder, is exempt from the OBRA-87
preadmission screening requirements.
(ii) The Health and Human Services (HHS)
draft criteria seek to limit the OBRA-87 definition to only those individuals
with the following types of major mental disorders: schizophrenic; paranoid;
major affective; schizoaffective; and atypical psychotic. The Department will
apply this limiting definition of mental illness. Thus, an individual has a
primary or secondary diagnosis of mental illness for OBRA-87 screening purposes
only if the condition falls within the definitions of schizophrenic, paranoid,
major affective, schizoaffective or atypical psychotic disorders.
(iii) Since OBRA-87 focuses on the actual
condition of the individual seeking admission, the HHS draft criteria indicate
that certain information in addition to the diagnoses be reviewed and that the
information can be the basis for screening even if the individual does not have
a primary or secondary diagnosis of mental illness. The Department will apply
these additional criteria. Thus, except as provided in paragraph (3), an
individual shall be screened, for OBRA-87 purposes, even if they do not have a
primary or secondary diagnosis of mental illness, if one of the following
applies:
(A) The individual has a history of
mental illness-as limited by definitions in this subparagraph-within the last 2
years.
(B) The individual has been
prescribed a major tranquilizer on a regular basis in the absence of a
justifiable neurological disorder.
(C) There is presenting evidence of mental
illness-as limited by definitions in this subparagraph-including possible
disturbances in orientation, affect or mood.
(iv) If the individual has a primary
diagnosis of dementia-as defined in this subparagraph-even if the individual
meets one or more of the additional criteria, the individual is exempt from the
preadmission screening process.
(2)
Who is mentally retarded under
OBRA-87.
(i) OBRA-87 uses the term
"mentally retarded" to involve both individuals who are mentally retarded and
those who may not be mentally retarded, but have other related conditions under
42 U.S.C.A. §
1396d(d).
(A)
Individuals who are mentally
retarded. Mental retardation is defined as having a level of
retardation-mild, moderate, severe or profound-as described in the American
Association on Mental Deficiency's Manual on Classification in Mental
Retardation (1983).
(B)
Individuals with other related conditions. Other related
conditions are defined by 42
CFR 435.1009 (relating to definitions
relating to institutional status), and include cerebal palsy and epilepsy, as
well as other conditions-such as autism-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 similar to
that of persons with mental retardation, and requires treatment or services
similar to those required for the mentally retarded. Related conditions are
conditions which are:
(I) Manifested before
age 22.
(II) Likely to continue
indefinitely.
(III) Resulting in
substantial functional limitations in three or more of the following areas of
major life activity:
(-a-) Self-care.
(-b-) Understanding and use of language.
(-c-) Learning.
(-d-) Mobility.
(-e-) Self-direction.
(-f-) Capacity for independent living.
(ii) Thus, for OBRA-87
purposes, a person is subject to preadmission screening if that individual:
(A) Has a diagnosis that fits the definitions
of "Mental retardation" or "other related conditions" in clauses (A) and
(B).
(B) Has a history of a
condition that fits the definitions.
(C) Presents evidence-cognitive or behavior
functions-that may indicate those conditions.
(D) Is referred by an agency that serves
persons with those conditions and has been found eligible for services by the
agency.
(3)
Exceptions to the rule.
(i)
Exceptions to the rule are as follows:
(A)
Convalescent care. An individual who may otherwise be mentally
ill or mentally retarded or who has another related condition under OBRA-87,
but is not a danger to himself or others, may be admitted to a nursing facility
without going through the OBRA-87 preadmission screening process for up to 120
days as part of a medically prescribed period of recovery after release from an
acute care hospital. If a person admitted under this exception requires more
than 120 days of recovery, a determination permitting the continued stay shall
be sought promptly.
(B)
Terminal illness. An individual who may otherwise be mentally
ill or mentally retarded or who has another related condition under OBRA-87,
but is not a danger to himself or others, may be admitted to a nursing facility
without going through the OBRA-87 preadmission screening process, if certified
by a physician to be terminally ill-as defined in
42 U.S.C.A. §
1395x(dd)(3)(A) -and
requiring continuous nursing care or medical supervision and treatment, or
both, due to the individual's physical condition. "Terminally ill" is defined
in 42 U.S.C.A. §
1395x(dd)(3)(A) as an
individual who has a medical prognosis of a life expectancy of 6 months or
less.
(C)
Severity of
illness. An individual who may otherwise be mentally ill or mentally
retarded or who has another related condition under OBRA-87 may be admitted to
a nursing facility without going through the OBRA-87 preadmission screening
process if certified by a physician to be comatose, ventilator dependent,
functioning at the brain stem level or having a diagnosis of either Chronic
Obstructive Pulmonary Disease, Severe Parkinson's Disease, Huntington's
Disease, Amyotrophic Lateral Sclerosis, Congestive Heart Failure or another
diagnosis later determined by the Health Care Financing Administration (HCFA)
to be sufficient.
(D)
Not
mentally ill or mentally retarded. An individual who is not mentally
ill, mentally retarded, who doesn't have another related condition, as defined
by OBRA-87, and who is not otherwise subject to preadmission screening as
described in this subparagraph may be admitted to a nursing facility without
going through the OBRA-87 preadmission screening process.
(ii) Thus, a person who qualifies for an
exception in this paragraph may be admitted to a nursing facility without
further determinations by the Department within the OBRA-87 preadmission
screening process.
(4)
Necessary documentation. A nursing facility provider-except an
ICF/MR-is required to comply with the preadmission screening process as a
condition of continuing participation in the Medical Assistance Program. The
process involves certain documentation requirements with respect to individuals
who are subject to preadmission screening and individuals who are not.
(i)
Form PA-PASARR-ID.
(A) The Department will require the use of
Form PA-PASARR-ID by a nursing facility subject to the OBRA-87 requirement.
Form PA-PASARR-ID is designed to evaluate whether an applicant for admission to
the nursing facility is subject to the determination requirements of OBRA-87
and, if not, to document the bases for excepting that individual from the
process.
(B) The record of each
resident admitted to a nursing facility on or after January 1, 1989 shall
include the completed Form PA-PASARR-ID for that resident. Failure to maintain
documentation of the completion of the form in a resident's record shall be a
basis for the disallowance of payment under the Medical Assistance Program with
respect to that resident under §§
1101.51(e),
1101.61,
1101.71(a) and
1101.83(a), and
may be a basis for the termination of the provider agreement or for the
imposition of another sanction permitted by law.
(C) Where Form PA-PASARR-ID indicates that an
applicant for admission is subject to further preadmission screening by the
Department, the provider shall refer the applicant to the appropriate agency,
for evaluation, and shall provide the agency and the applicant with a copy of
the completed Form PA-PASARR-ID. The applicant-including a legal or personal
representative acting on behalf of the applicant-shall have the right to appeal
a referral. The appeals process is described in §
1181.561 (relating to process to
appeal adverse determinations in the preadmission screening program). An
attachment to form PA-PASARR-ID provides the applicant with notice of the
appeals process.
(D) Completion of
Form PA-PASARR-ID does not replace Department requirements with respect to Form
MA-51. When Form MA-51 is required by current Department procedures, that form
shall be filed as well as Form PA-PASARR-ID.
(ii)
Form PA-PASARR-YN.
(A) The determinations of whether individuals
requiring preadmission screening require nursing facility services and, if they
do, whether they require active treatment shall be issued to the involved
applicants for admission to the facility on Form PA-PASARR-YN. No individual
who has been referred by a provider for evaluation may be admitted to the
nursing facility without presenting Form PA-PASARR-YN authorizing admission for
copying and verification by the provider.
(B) Providers are required to maintain their
copy of Form PA-PASARR-YN as part of the record of a person admitted to the
facility on or after January 1, 1989. Certification to the provider on Form
PA-PASARR-YN, verified by the agency designated by the Department of Aging to
manage the evaluation process, is the only acceptable evidence as to whether a
person who has been referred by the provider for further determination under
the preadmission screening process has been determined to be eligible for
admission. The Department will not make payment for services provided to a
resident referred for preadmission screening process determinations unless the
Department has certified on Form PA-PASARR-YN that the resident requires the
level of services provided in a nursing facility.
(C) A copy of the completed Form PA-PASARR-YN
is provided to each applicant who has been referred for further determination.
The applicant-including a legal or personal representative acting on behalf of
the applicant-shall have the right to appeal from a determination. The form
provides the applicant with notice of the appeals process.
Notes
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