CMS SOM App. PP, Tag F645

with intellectual disability.

§483.20(k)(1) A nursing facility must not admit, on or after January 1, 1989, any new

residents with:

(i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State

mental health authority has determined, based on an independent physical and

mental evaluation performed by a person or entity other than the State mental

health authority, prior to admission,

(A) That, because of the physical and mental condition of the individual, the

individual requires the level of services provided by a nursing facility; and

(B) If the individual requires such level of services, whether the individual requires

specialized services; or

(ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the

State intellectual disability or developmental disability authority has determined

prior to admission—

(A) That, because of the physical and mental condition of the individual, the

individual requires the level of services provided by a nursing facility; and

(B) If the individual requires such level of services, whether the individual requires

specialized services for intellectual disability.

§483.20(k)(2) Exceptions. For purposes of this section-

(i)The preadmission screening program under paragraph(k)(1) of this section 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.

(ii) The State may choose not to apply the preadmission screening program under

paragraph (k)(1) of this section to the admission to a nursing facility of an

individual-

(A) Who is admitted to the facility directly from a hospital after receiving acute

inpatient care at the hospital,

(B) Who requires nursing facility services for the condition for which the individual

received care in the hospital, and

(C) 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.

§483.20(k)(3) Definition. For purposes of this section-

(i) An individual is considered to have a mental disorder if the individual has a serious

mental disorder defined in 483.102(b)(1).

(ii) An individual is considered to have an intellectual disability if the individual has an

intellectual disability as defined in §483.102(b)(3) or is a person with a related

condition as described in 435.1010 of this chapter.

INTENT §483.20(k)(1)-(3)

To ensure each resident in a nursing facility is screened for a mental disorder (MD) or

intellectual disability (ID) prior to admission and that individuals identified with MD or ID are

evaluated and receive care and services in the most integrated setting appropriate to their needs.

DEFINITIONS §483.20(k)(1)-(3)

“Intellectual Disability (ID)” is defined in 42 CFR §483.102(b)(3) as follows:

An individual is considered to have intellectual disability (ID) if he or she has—

(i) A level of retardation (mild, moderate, severe or profound) described in the American

Association on Intellectual’s Disability Manual on Classification in Intellectual Disability

(1983);or

(ii) A related condition as defined by §435.1010 of this chapter.

“Mental Disorder (MD)” For purposes of this section, the term “mental disorder” is the

equivalent of “mental illness” used in the definition of serious mental illness in 42 CFR

§483.102(b)(1), which states:

An individual is considered to have a serious mental illness (MI) if the individual meets 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, 3rd edition, revised in 1987.

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; but

(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.

(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.

(iii) Recent treatment. The treatment history indicates that the individual has experienced at

least one of the following:

(A) Psychiatric treatment more intensive than outpatient care more than once in the past 2

years (e.g., partial hospitalization or inpatient hospitalization); or

(B) Within the last 2 years, due to the mental disorder, experienced an episode of

significant disruption to the normal living situation, for which supportive services

were required to maintain functioning at home, or in a residential treatment

environment, or which resulted in intervention by housing or law enforcement

officials.

“Persons with Related Conditions” is defined in 42 CFR §435.1010 as follows:

Persons with related conditions means individuals who have a severe, chronic disability that

meets all of the following conditions:

(a) It is attributable to—

(1) Cerebral palsy or epilepsy; or

(2) Any other condition, other than a mental illness, found to be closely related to

Intellectual Disability because this condition results in impairment of general

intellectual functioning or adaptive behavior similar to that of mentally retarded

persons, and requires treatment or services similar to those required for these persons.

(b) It is manifested before the person reaches age 22.

(c) It is likely to continue indefinitely.

(d) It results in substantial functional limitations in three or more of the following areas of

major life activity:

(1) Self-care.

(2) Understanding and use of language.

(3) Learning.

(4) Mobility.

(5) Self-direction.

(6) Capacity for independent living.

“Preadmission Screening and Resident Review (PASARR)” is a federal requirement to help

ensure that individuals are not inappropriately placed in nursing homes for long term care.

PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for

serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting

for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the

services they need in those settings. Regulations governing PASARR are found at 42 CFR

§483.100-§483.138.

“Specialized Services for MD or ID” means the services specified by the State that exceed the

services ordinarily provided by the nursing facility (NF) under its per diem rate. These services

must be provided or arranged by the state and could include hiring additional staff or contractors

such as qualified mental health/intellectual disability professionals. When specialized services

are combined with services provided by the nursing facility, the result is a continuous and

aggressive implementation of an individualized plan of care for individuals with MD or ID. The

resident’s Level II PASARR identifies the specialized services required by the resident.

“Rehabilitative services for MD or ID” refers to those services of lesser frequency or intensity

to be implemented by all levels of nursing facility staff that come into contact with any resident

who has as mental disorder or who has intellectual disability. These services are necessary

regardless of whether or not they are specified in the PASARR Level II documents and whether

or not the resident requires additional services to be provided or arranged for by the State.

GUIDANCE §483.20(k)(1)-(3)

The PASARR process requires that all applicants to Medicaid-certified nursing facilities be

screened for possible serious mental disorders, intellectual disabilities and related conditions.

This initial screening is referred to as Level I Identification of individuals with MD or ID

(§483.128) and is completed prior to admission to a nursing facility. The purpose of the Level

I pre-admission screening is to identity individuals who have or may have MD/ID or a related

condition, who would then require PASARR Level II evaluation and determination prior to

admission to the facility.

A negative Level I screen permits admission to proceed and ends the pre-screening process

unless possible serious mental disorder or intellectual disability arises later. A positive Level 1

screen necessitates an in-depth evaluation of the individual, by the state-designated authority,

known as Level II PASARR, which must be conducted prior to admission to the facility.

Failure to pre-screen residents prior to admission to the facility may result in the failure to

identify residents who have or may have MD, ID or a related condition. A record of the pre-screening should be retained in the resident’s medical record.

Individuals who have or are suspected to have MD, ID or a related condition (as indicated by a

positive Level 1 screen) may not be admitted to a Medicaid-certified nursing facility unless

approved based on Level II PASARR evaluation and determination. Exceptions to this

requirement are specified in §483.20(k)(2) and may be exercised at the discretion of the State,

as specified in the State’s PASARR process.

Level II PASARR is a comprehensive evaluation conducted by the appropriate state-designated authority that determines whether an individual has MD, ID or a related condition

as defined above, determines the appropriate setting for the individual, and recommends what,

if any, specialized services and/or rehabilitative services the individual needs. The Level II

PASARR cannot be conducted by the nursing facility.

Each State Medicaid Agency has specific processes for conducting Level I screens and Level

II PASARR evaluations and determinations. Exceptions to the pre-screening requirements are

specified in §483.20(k)(2) and may be exercised at the discretion of the State, as specified in

the State’s PASARR process. Facility staff and surveyors should be acquainted with their

States’ requirements.

If the State program permits the use of the exceptions specified in §483.20(k)(2), and the

resident remains in the facility longer than 30 days, the facility must screen the individual

using the State’s Level I screening process and refer any resident who has or may have MD,

ID or a related condition to the appropriate state-designated authority for Level II PASARR

evaluation and determination. NOTE: under 42 CFR 483.106(b)(2)(ii), If an individual who

enters a NF as an exception (an exempted hospital discharge) is later found to require more

than 30 days of NF care, the State mental health or intellectual disability authority must

conduct a Level II resident review within 40 calendar days of admission.

The State is responsible for providing or arranging for specialized services for residents with

MD or ID residing in Medicaid-certified facilities. The facility is required to provide all other

care and services appropriate to the resident’s condition. Therefore, if a facility has residents

with MD or ID, do not survey for specialized services, but survey for all other requirements,

including resident rights, quality of life, and quality of care.

PROCEDURES AND PROBES §483.20(k)(1)-(3)

• If the resident’s Level II PASSR report indicates that he or she needs specialized services

but the resident is not receiving them, the State Survey Agency would notify the State-designated mental health or intellectual disability authority that evaluated the resident

prior to admission. NF services alone are not ordinarily of the intensity to meet the needs

of residents with MD or ID.

• Is there evidence of Level I pre-screening of residents prior to admission to the nursing

facility to identify residents who have or may have MD, ID or a related condition, who

requires Level II PASARR evaluation?

• Are residents with a positive Level I PASARR screen evaluated by the designated state-authority, through the Level II PASARR process, and approved for admission prior to

admission to the nursing facility?

• If pre-admission screening of residents expected to be in the facility 30 days or less is not

performed, in accordance with the State PASARR process, does the facility screen

residents who have or may have MD, ID or a related condition, if the resident remains in

the facility longer than 30 days? Are residents who have a positive screen then referred

to the appropriate state-authority for Level II evaluation and determination?

If the resident has a MD or ID, did the State Mental Health or Intellectual Disabilities

Authority determine:

• Whether the residents needed the services of a nursing facility

• Whether the residents need specialized services for their MD or ID?

DEFICIENCY CATEGORIZATIONS

Severity Level 4 Considerations: Immediate Jeopardy to Resident Health or Safety

An example of Level 4, immediate jeopardy to resident health and safety, include, but is not

limited to:

• A resident with bipolar disorder was newly admitted to the facility prior to Level II

PASARR evaluation and determination. The facility’s failure to ensure the Level II

PASARR process was completed prior to admission resulted in the resident no longer

receiving needed psychotherapy 4 times per week. The interruption in receiving needed

psychotherapy services caused the resident to relapse into a depressive state, during

which the resident engaged in social withdrawal and self-cutting behaviors resulting in

hospitalization of the resident.

Severity Level 3 Considerations: Actual Harm that is not Immediate Jeopardy

An example of Level 3, actual harm that is not immediate jeopardy includes but is not limited to:

• The facility failed to ensure Level 1 pre-screening of a new resident for MD/ID or a

related condition prior to admission to the facility. The resident had cerebral palsy,

which is a related condition. The lack of pre-screening resulted in the resident’s

condition not being identified prior to admission and the resident not being evaluated

through the Level II PASARR process. The resident did not receive the specialized

rehabilitation services she needed which resulted in a decline in her function.

Severity Level 2 Considerations: No Actual Harm with Potential for More Than Minimal

Harm that is Not Immediate Jeopardy

An example of Level 2, no actual harm, with potential for more than minimal harm, that is not

immediate jeopardy, includes, but is not limited to:

• The facility failed to ensure Level 1 pre-screening of new residents for MD/ID or a

related condition, prior to admission to the facility. While the residents did not have

MD/ID or a related condition, the facility admitted the residents without knowing if the

residents had one of these conditions. The failure to determine whether the residents had

MD/ID or a related condition had the potential to cause more than minimal harm to new

and/or current residents.

Severity Level 1: No Actual Harm with Potential for Minimal Harm

Failure to ensure residents are pre-screened for MD/ID or a related condition, prior to admission

to the facility, could prevent the resident from attaining or maintaining his/her highest practicable

level or result in a decline in the resident’s physical, mental or psychosocial well-being.

Therefore, Severity Level 1 does not apply for this regulatory requirement.