LEVEL I PAS

Q: Why does the nursing facility need to document the date and time the Level I PAS was completed?

Q: Is another Level I PAS required when a resident returns from MLOA to the same nursing facility?

Q: Does a nursing facility need to complete a Level I PAS when accepting a resident from another nursing facility?

Q: Who can certify the 30 day convalescent stay?

Q: In circumstances where an individual is being admitted during off hours ( late evening, night or early morning) or on a weekend day can the Level I PAS wait until the next morning or next business day?

Q: What would the Nursing Facility do if they find out after admission that a resident has a mental illness, intellectual or other developmental disability that was not listed on the discharge paperwork?

Q: What if a resident is on a psychoactive medication that is not being used for the treatment of a mental illness but is being used for another diagnosis; must this medication be documented on the Level I PAS?

Q: If a family member can validate the date of depression is that sufficient?

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LEVEL II PASRR

Q: When a referral is made to DMH/HES or DDS in what timeframe should the Level II PASRR Evaluation and Determination be completed?

Q: A potential nursing facility resident has both a MI and ID/DD. Does he/she require both Level II PASRR screenings?

Q: Does an individual with a diagnosis of MI, ID/ DD coming form another state to a MA nursing facility need to have the Level II PASRR prior to admission?

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LEVEL II PASRR- MENTAL ILLNESS

Q: How long is a Level II PASRR mental illness Evaluation valid?

Q: If a nursing facility resident with psychiatric illness is admitted for a MEDICAL reason to an AIH then placed in a different nursing facility upon discharge, is another Level II PASRR for mental illness required?

Q: Is a Level II PASRR for mental illness required if the mental illness is not the PRIMARY DIAGNOSIS?

Q: To what does "a 10 year history" refer when dealing with unipolar depression?

Q: If an individual does NOT have a 10 year history of depression but HAS received medications, hospitalizations or ECT treatments for depression, does a facility need to refer for Level II PASRR Evaluation and Determination?

Q: If an individual has a major mental illness and dementia; when may dementia be used as a categorical determination from the Level II PASRR for mental illness?

Q: If an individual has less than six (6) months to live but the documentation states a prognosis of six to nine (6-9) months, is a Level II PASRR for mental illness required?

Q: If an individual is admitted to a nursing facility from an AIH for LESS THAN 30 days, is a Level II PASRR for mental illness required? What documentation is sufficient to qualify for the categorical determination?

Q: Is an order signed by a nurse practitioner or nurse clinician acceptable to qualify for a 30-day convalescent care exemption

Q: A complete Level II PASRR for mental illness was performed 10 days ago and now the individual has been re-admitted to an inpatient psychiatric unit. Is another Level II PASRR Evaluation for mental illness required?

Q: Will the nursing facility be notified when a Level II PASRR Evaluation and Determination for mental illness has been performed in a psychiatric hospital?

Q: If a nursing facility resident with funding from another state (e.g., New York Medicaid) is admitted to a Massachusetts psychiatric hospital, should a Massachusetts perform the Level II PASRR Evaluation for?

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LEVEL II PASRR INTELLECTUAL/DEVELOPMENTAL DISABILITY

Q: What is an exempted hospital discharge for a Level II PASRR for ID/DD?

Q: When can I expect the Level II PASRR to take place?

Q: What can I expect to happen during a Level II PASRR Evaluation for ID/DD?

Q: If the NF has been in contact with DDS throughout this process, do they still need to call regarding an admission? If so, what is the correct number?

Q: What happens if the individual requires continued nursing facility stay beyond a short-term authorization?

Q: What happens if the individual still requires continued nursing facility care beyond a second short-term 90 day authorization?

Q: If DDS has determined that the individual no longer needs NF level of services what is their responsibility?

Q: What if the individual disagrees with the Level II PASRR findings and wants to stay in the NF?

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LEVEL I PAS

Q: Why does the nursing facility need to document the date and time the Level I PAS was completed?
A:
Federal regulations require the Level I PAS be completed prior to admission. The date and time verify that the Level I PAS was completed prior to admission.

Q: Is another Level I PAS required when a resident returns from MLOA to the same nursing facility?
A:
No, a Level I PAS is not required when the resident returns to the same nursing facility following a MLOA.

Q: Does a nursing facility need to complete a Level I PAS when accepting a resident from another nursing facility?
A:
Yes, all new admissions require a Level I PAS.

Q: Who can certify the 30 day convalescent stay?
A:
Only an acute inpatient hospital (AIH) physician can certify the 30 day convalescent stay. Such certification of the 30 day convalescent stay must be included as part of the hospital discharge orders.

Q: In circumstances where an individual is being admitted during off hours ( late evening, night or early morning) or on a weekend day can the Level I PAS wait until the next morning or next business day?
A:
No. The Level I PAS must be completed prior to admission. You may not admit an individual if the Level I PAS indicates a Level II PASRR referral is required except in a circumstance where the individual is under protective services. ;The facility may admit but must complete all PASRR.

Q: What would the Nursing Facility do if they find out after admission that a resident has a mental illness, intellectual or other developmental disability that was not listed on the discharge paperwork?
A:
The nursing facility will need to add a late entry to the Level I PAS indicating the diagnosis. If the diagnosis is a categorical determination (MI only), no referral is necessary for a Level II PASRR Evaluation and Determination. However, if the diagnosis is not a categorical determination, then the facility must immediately make the referral DDS and/or DMH/HES.

Q: What if a resident is on a psychoactive medication that is not being used for the treatment of a mental illness but is being used for another diagnosis; must this medication be documented on the Level I PAS?
A:
Yes. The medication and the reason for its use must be documented on the Level I PAS. If documented appropriately, no referral for Level II PASRR is necessary.

Q: If a family member can validate the date of depression is that sufficient?
A:
No. There must be clinical documentation of the date of onset.

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LEVEL II PASRR

Q: When a referral is made to DMH/HES or DDS in what timeframe should the Level II PASRR Evaluation and Determination be completed?
A:
DMH/HES and DDS must make pre-admission determination in writing within an annual average of 7 to 9 days from the date of the referral however if the individual enters due to an exempted hospital discharge( 30 day convalescent stay) that ends up requiring greater than 30 days the determination must be conducted within 40 days of admission.

Q: A potential nursing facility resident has both a MI and ID/DD. Does he/she require both Level II PASRR screenings?
A:
Yes. An individual with a dual diagnosis will require both Level II PASRR screenings. Contact DMH/HES and DDS for Level II PASRR Evaluation.

Q: Does an individual with a diagnosis of MI, ID/ DD coming form another state to a MA nursing facility need to have the Level II PASRR prior to admission?
A:
Yes. The sending state must complete the Level II PASRR and send the completed Level II PASRR Evaluation and Determination and approval for admission to the MA nursing facility.

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LEVEL II PASRR- MENTAL ILLNESS

Q: How long is a Level II PASRR mental illness Evaluation valid?
A:
A Level II PASRR Evaluation and Determination for mental illness is valid until one or more of the following occurs:

  • An inpatient psychiatric hospitalization;
  • A nursing facility resident is discharged to the community, has a significant change in their mental status and wishes to be re-admitted to any nursing facility;
  • A federal or state level auditor requests a screening. The Department of Mental Health reserves the right to determine the necessity of the request; or
  • A significant change in mental status has occurred that results in a new psychiatric diagnosis for a nursing facility resident

Q. If a nursing facility resident with psychiatric illness is admitted for a MEDICAL reason to an AIH then placed in a different nursing facility upon discharge, is another Level II PASRR for mental illness required?
A:
No. The only times that individual will require another Level II PASRR for mental illness is if a.) they are admitted to an in-patient psychiatric hospital, or b) they return to the community and then they are re-admitted to a nursing facility.

Q: Is a Level II PASRR for mental illness required if the mental illness is not the PRIMARY DIAGNOSIS?
A:
Yes. Any diagnosis of mental illness that meets the criteria for Level II PASRR Evaluation and Determination must be referred, regardless of its place in the listing of a patient's diagnoses.

Q: To what does "a 10 year history" refer when dealing with unipolar depression?
A:
"10 year history" refers to at least one episode of depression for which the individual has received medication, hospitalization, ECT and/or counseling treatment. This treatment documentation should include the date(s) of treatment that will establish the history. Please note that the individual may experience periods of remission but history will begin with the earliest date of treatment. Also there is no limit on the number of hospitalizations, ECT treatment or type/duration of medication.

Q: If an individual does NOT have a 10 year history of depression but HAS received medications, hospitalizations or ECT treatments for depression, does a facility need to refer for Level II PASRR Evaluation and Determination?
A:
No. The individual must have a 10-year history of depression and at least one of the qualifying criteria. However, proper documentation should include the dates of any treatments in order to establish a reliable history.

Q: If an individual has a major mental illness and dementia; when may dementia be used as a categorical determination from the Level II PASRR for mental illness?
A:
Dementia may be used as a categorical determination from Level II PASRR only when it is properly documented. Proper documentation includes any of the following: results of neurological scans (CT, PET, MRI, etc) documenting significant atrophy, results of neuro-psychological testing performed by a PhD-level psychologist documenting dementia by psychometric testing, notes in nursing/social service section of the record documenting cognitive and/or behavioral declines in functioning consistent with the diagnosis of dementia over a specified period of time. Please note that the diagnosis of dementia MUST appear in the official listing of diagnoses assigned by the primary care physician.

Q: If an individual has less than six (6) months to live but the documentation states a prognosis of six to nine (6-9) months, is a Level II PASRR for mental illness required?
A:
Yes. The documentation must state a prognosis of six months or less to preclude the requirement for a Level II PASRR Evaluation, and it must be signed by a physician.

Q: If an individual is admitted to a nursing facility from an AIH for LESS THAN 30 days, is a Level II PASRR for mental illness required? What documentation is sufficient to qualify for the categorical determination?
A:
No. A Level II PASRR for mental illness is not required for an admission to a nursing facility that is not anticipated to be longer than 30 days and is documented by the AIH physician. ;The order for care must state that a stay of less than 30 days is required. A time frame in days must be specified. The phrase "short term rehab" is NOT sufficient to qualify for an exemption.

Q: Is an order signed by a nurse practitioner or nurse clinician acceptable to qualify for a 30-day convalescent care exemption?
A:
No. The order for continuing medical care, specified in number of days, MUST be signed by the AIH physician prior to admission to a nursing facility.

Q: A complete Level II PASRR for mental illness was performed 10 days ago and now the individual has been re-admitted to an inpatient psychiatric unit. Is another Level II PASRR Evaluation for mental illness required?
A: Yes. An inpatient psychiatric admission constitutes a significant change in the individual's mental status. For that reason another Level II PASRR for mental illness must be completed if the individual meets the criteria and has no categorical determination.

Q: Will the nursing facility be notified when a Level II PASRR Evaluation and Determination for mental illness has been performed in a psychiatric hospital?
A: Yes. Written notification of screenings are faxed and/or mailed to the nursing facility when results are reported to Health & Education Services, Inc. The nursing facility may also contact the OBRA Offices at Health & Education Services, Inc., to confirm that a screening has been completed.

Q: If a nursing facility resident with funding from another state (e.g., New York Medicaid) is admitted to a Massachusetts psychiatric hospital, should a Massachusetts perform the Level II PASRR Evaluation for?
A:
No. The state sending is responsible for completing the Level II PASRR and issuing a determination. The sending state is also responsible to pay for the Level II PASRR and any and all services that individual requires.

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LEVEL II PASRR INTELLECTUAL/DEVELOPMENTAL DISABILITY

Q: What is an exempted hospital discharge for a Level II PASRR for ID/DD?
A: The criteria for an exempted hospital discharge are:

  • The individual is admitted to a nursing facility directly from a hospital after receiving acute inpatient care; and
  • The individual requires nursing facility services for the condition for which he/she received care in the hospital; and
  • The individual is likely to require less than thirty (30) days of nursing facility services. This must be documented by the AIH physician and be included with the discharge paperwork.

Q: When can I expect the Level II PASRR to take place?
A: As stated in the first question under LEVEL II PASRR, a pre-admission determination will be made in writing within 7 - 9 days of referral except in circumstances where the individual enters due to an exempted hospital discharge( 30 convalescent stay) that ends up requiring greater than 30 days the determination will be conducted within 40 days of admission.

Q: What can I expect to happen during a Level II PASRR Evaluation for ID/DD?
A: You can expect a Regional Nursing Facility Specialist to visit the individual at their current location. They will visit with the individual seeking admission if possible, and will speak with involved medical and/or social service staff. The Nursing Facility Specialist will also conduct a record review, will contact family members and/or guardians, and may speak with any other involved staff.

Q: If the NF has been in contact with DDS throughout this process, do they still need to call regarding an admission? If so, what is the correct number?
A:
Do not assume that because you have contacted DDS you are not still required to contact DDS to make the Level II PASRR referral. Nursing facilities are required to report to DDS all admission by phone on the day of admission or the first business day following admission and by fax within 48 hours.

  • The phone number is (617) 624-7796 and the fax number is (617) 624-7557.

Q: What happens if the individual requires continued nursing facility stay beyond a short-term authorization?
A: Prior to the expiration of the short-term Level II PASRR determination, the Regional Nursing Facility Specialist who conducted the previous PASRR screen will contact the nursing facility and other members of the team to obtain an update of the individual's status. If it is determined by DDS that the individual continues to need nursing facility level of service, another determination notice may be issued that would authorize another short-term approval for up to 90 days.

Q: What happens if the individual still requires continued nursing facility care beyond a second short-term 90 day authorization?
A: The Regional Nursing Facility Specialist who conducted the two prior Level II ID/DD PASRR screen will contact the nursing facility and other members of the team to obtain an update of the individual's status. If it is determined by DDS that the individual continues to need nursing facility level of service, another determination notice may be issued that would authorize another nursing facility stay without a specific end date.

Q: If DDS has determined that the individual no longer needs NF level of services what is their responsibility?
A:
DDS is responsible for arranging for the individual safe and orderly discharge; preparing and orienting the individual for discharge, and for providing or arranging for the provision of the appropriate services that will meet the individuals needs. 42 CFR 483.118 (c)(2). The nursing facility is responsible for executing the members discharge in accordance with 42 CFR 483.12(a).

Q: What if the individual disagrees with the Level II PASRR findings and wants to stay in the NF?
A:
Every individual, regardless of payer source, has the right to appeal the Level II PASRR decision and if filed within the prescribed times frame, will be granted a fair hearing. Each notice of determination contains information on appeal rights.

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