Guidance
- Letter is also available in Portable Document Format
What are Categorical Determinations?
Cases that fall under categorical determinations do not require a Level II PASARR assessment prior to NF admission, but do require documentation in the medical record.
The following four (4) categories may be applicable to individuals identified by Level I SCREENs as possibly having MI, ID and/or ID when existing documentation on the individual are current and accurate and are sufficient to allow the reviewer to readily determine that the individual fits the category:
- Convalescent Care – a medically prescribed, time–limited period of post–acute hospital care recovery in a NF not to exceed one hundred and twenty (120) days as documented by the acute care physician in the medical record.
- Seriously ill – can include a person being comatose, ventilator dependent, or having a diagnosis of one or more chronic debilitating conditions at a severe level.1
- Terminally ill – life expectancy of six (6) months or less for which there is documentation by a physician in the medical record.
- Brief Finite Stay or Provisional emergency admission – a brief and finite stay define as stay in which the duration is expected to be 30 days or less (e.g., scheduled short term care stay (respite). A provisional emergency admission is a stay in which the duration is not to exceed 7 days and the purpose is to provide protective services.
To ensure due diligence by Nursing Homes, the following is recommended:
- Obtain information confirming the categorical determination criteria has been met prior to admission.
- Have policies and procedures for Level I SCREEN and PASARR Level II including how the facility will track residents who fall under a categorical determination. If admission exceeds the specified time limits, or the categorical determination no longer applies, this will trigger a significant change in condition assessment and a PASARR Level II Resident Review must be initiated.
What is a Significant Change in Physical or Mental Condition?
What constitutes a significant change in condition? A significant change in status is best understood by looking at these three criteria regarding the resident´s condition:
- Will not normally resolve itself without interventions,
- Impacts more than one area of the individual´s health status, and
- Requires an interdisciplinary review and/or revision of the current plan of care.
The Long Term Care Facility Resident Assessment Instrument 3.0 User´s Manual, version 1.5), the State Operations Manual (SOM) Appendix PP – Guidance to Surveyors for Long Term Care Facilities page 201, F646 483.20(k)(4), and the PTAC website provides guidance to Nursing Homes on when a significant change requires referral for a PASARR if SMI, ID/DD, or RC are present. The PASARR, the Minimum Data Set (MDS), and the SOM definition of significant change is the same.
Remember: You need not wait until the significant change MDS is completed to make a PASARR referral.
When a PASARR identified Nursing Home resident is admitted to an acute care facility, for either medical or psychiatric reasons, staff should initiate communication with acute care facility staff to discuss the individual´s clinical condition, and relevant updates as they unfold. In many, if not most cases, a Level II PASARR referral will be necessary.
Acute care and Nursing Home staff, working together, will not only recognize if/how an individual has experienced a significant change in condition, but will also determine the optimal time when a PASARR Level II referral should be made.
What Triggers a Resident Review?
A Resident Review is triggered when a change in condition or behavior is observed. For an individual not previously identified by PASARR to have a MI, DD/ID, or RC, a Resident Review would be required if he or she:
- Exhibits behavioral, psychiatric, or mood–related symptoms suggesting the presence of a diagnosis of mental illness; Excludes 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 under 42 CFR § 483.102(b)(1)
- Whose intellectual disability as defined under 42 CFR §483.102 or whose related condition as defined under 42 CFR §435.1010 was not previously defined and evaluated through PASARR; or
- Is transferred, admitted, or readmitted to a nursing home following an inpatient psychiatric stay or equally intensive treatment.
Please Note: The above–and below referenced examples are not limited to and are not meant to represent an exhaustive list
For an individual previously identified by PASARR to have a MI, DD/ID, or RC, a Resident Review would be required if a resident:
- Demonstrates increased behavioral, psychiatric or mood–related symptoms;
- Presents with behavioral, psychiatric or mood–related symptoms that have not responded to ongoing treatment;
- Indicates a preference to leave the nursing home, communicated verbally or through some other forms of communication, including behavior;
- Experiences an improved medical condition, and as such, their plan of care or placement recommendations may require modification; or,
- Whose significant change is physical, but with behavioral, psychiatric, or mood–related symptoms, or cognitive abilities that may create an altered pattern of daily living.
Remember: significant change can also be a major improvement in condition.
Finally, when a nursing facility identifies a significant improvement in condition for an individual with MI, DD/ID or RC, and the individual wishes to return to the community, the Nursing Home must begin discharge planning and make a referral to the Open Doors Transition Center. The Open Doors Transition Center is a referral program, administered for DOH through the New York Association of Independent Living (NYAIL), that assists nursing facility residents with transitioning to more independent, community–based living. NYAIL is the DOH–designated Local Contact Agency for MDS 3.0 Section Q referrals. For more information, or to make a referral, call 1–888–545–7108 or email secq@ilny.org.
Specific questions related to the Level I SCREEN, please call 518–408–1267 or email DOH.SM– PRI–SCREEN
Level II PASRR Referral for Mental Illness
In an important change this year, NYS now contracts with Ascend, a MAXIMUS Company, to perform Level II evaluations. A referral must include: 1) an Intake form; 2) History and Physical Evaluation; 3) H/C PRI; and, 4) SCREEN.
Additional documents, when applicable and available, may help expedite a Level II evaluation, such as: recent nursing notes, a current Medication Administration Record (MAR); Psychosocial Evaluation or history; recent progress notes; neurological consultation/testing if completed; and recent PT or OT notes, when documenting functional status. Social services and discharge planning notes relevant to the current PASRR request, indicating whether any alternative community supports were explored would also be helpful.
Please Note: If you are sending referrals for more than one individual, each referral should be sent separately with its own fax cover sheet. The Ascend Intake Form and their NY–specific fax cover sheet is available here.
Specific questions regarding New York´s PASRR Level II process may be answered by e–mailing Ascend at: Ascend–NYPASRR@maximus.com , calling the Ascend New York PASRR Help Desk: 877–431–1388, ext. 3475 or by emailing pasrr@health.ny.gov.
Level II PASRR Referral for Developmental or Intellectual Disability, or Related Conditions
The NYS Office for People with Developmental Disabilities (OPWDD) is the agency overseeing services provided to persons with developmental or intellectual disabilities and the referral must be made to OPWDD if the individual has one of the defining or related conditions – with or without a diagnosis of MI.
According to 42 CFR 483.102 (b) (3), an individual has an intellectual disability if he or she has a level of intellectual disability as described in the American Association on Mental Retardation´s Manual on Classification, published in 1983, or a related condition which is defined by 42 CFR 435.1010.
OPWDD has agency–specific requirements for their referrals. In addition to the PASARR Level I SCREEN, OPWDD requires the PRI as part of the referral.
The OPWDD referral form can be accessed here.
For additional guidance, or with any questions, contact Barbara Fahey, OPWDD Statewide Coordinator for PASARR and Aging Services, at (518) 388–0694 or contact your OPWDD Regional PASARR Coordinator who can be found at the link above.
Additional Guidance
The PASRR Technical Assistance Center (PTAC), is contracted with CMS to provide training and technical assistance on Level I and Level II PASARR processes, which can be complex and generate many nuanced questions. To access valuable resources that addresses many PASARR questions, visit the PTAC website.
Any questions regarding the content of these guidelines, please contact the Department by emailing pasrr@health.ny.gov
_________________________________________
1. Chronic Obstructive Pulmonary Disease, Parkinson´s Disease, Huntington´s Disease, Amyotrophic Lateral Sclerosis or Congestive Heart Failure as documented in the medical record, and whose PRI or H/C PRI responses are 3, 4, or 5 (see PRI or H/C PRI Part III, items19–22). 1