Transcript PASSRR PRESENTATION - Welcome to the Tennessee …

PASRR PRESENTATION
Tennessee Bureau of TennCare
Level I Pre-Admission
Screening Resident Review
(PASRR)
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Requirement of the Federal Nursing
Home Reform law of 1987, nursing
homes must complete a screening
process BEFORE admitting any person
known or suspected to have a diagnosis
of mental retardation or mental illness
to ensure that placement in a nursing
home is in fact appropriate.
Current Level I PASRR Process
■ Tennessee nursing homes have been allowed
to submit their PASRR screenings up to 30
days AFTER admission, as the PASRR is a part
of the Pre-Admission Evaluation (PAE) level of
care application
 Nursing homes have been given up to 30 days
after admission to submit the PAE
applications
Effective July 1, 2009
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Tennessee will eliminate the 30 day PAE retro eligibility.
However, discussions are being held with nursing home
industry to possibly allow a lesser period of time for completing
Level of Care criteria, ONLY if PASRR is FULLY completed.
Tennessee NFs must comply with federal PASRR requirements
and complete the screening prior to admission.
If a Level I PASRR screen is positive, Medicaid payment will not
begin until Level II evaluation is completed and the recipient is
found to be appropriate for nursing facility placement.
Level I PASRR Requirements
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If individual meets certain MEDICAL
EXEMPTIONS or has a negative
response to Level One Screen, they
may be admitted to or continue to
reside in a Medicaid-certified Nursing
Facility without being determined
appropriate for nursing facility
placement thorough the Level II PASRR
process.
Level I PASRR Requirements
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Any individual for whom there is a positive response
for any of the criteria for Mental Retardation or
Mental Illness may not be admitted to or
continue to reside in a Medicaid-Certified nursing
facility without being determined appropriate for
nursing facility placement through the Level II PASRR
process.
Code of Federal Regulations (CFR) 483.122(b)….”FFP
is available only for services furnished after the
screening or review has been performed,..”
Level II Screen
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On site, face to face evaluation with the
individual that has a positive Level I PASRR
Purpose: To determine if an individual’s special
needs must be addressed in a NF or if those
needs are so significant that they cannot be
met in a NF.
Key Points for PASRR
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Level I Screening required on individuals
regardless of their payment source for
Medicaid Certified NF
If Level I positive, and no exemptions are met,
the applicant should not be admitted to
nursing home until completion of Level II
evaluation.
Exemptions for Positive Level I
Screens
When Level I screen indicates a positive response,
review to see if exemption is applicable
 Dementia (not for known or suspected MR)
 Terminal Illness-less than 6 months to live
 Short Term Convalescence (after hospitalization,
needed care that can not be >120 days from admit
date to NF)
 Severity of Illness-provide documentation
Physician must certify the exemption with signature and
date
PASARR Status Changes
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Resident not discovered on Pre-Admission
Screening to have MI, MR, or RC
Residents, previous identified through a Level
II PASRR evaluation, experiences a significant
increase in symptoms and/or behavior
problems
Resident that experiences a significant
improvement in their health status that could
possible then benefit from community services
For MI/RC Status changes
For MI/RC Status changes:
 Complete the DMHDD Report Form for
Change in Mental Status
 Fax completed form to DMHDD
(615) 741-6086
For MR Status changes
 Complete the DMRS Report Form for Change
in Mental/Health Status
 Fax to DMRS (615) 253-6713 or mail to
address on procedure
Division of Long Term Care
Executive Staff
TennCare
Pattie Killingsworth – Assistant Commissioner; Chief of Long Term
Care (LTC)
Richard Strecker - Deputy of LTC Operations
Mollie Mennell – Deputy LTC Quality & Administration
Nita Mangum – Deputy LTC Eligibility/Enrollment
Pat Santel – Director Institutional & PACE
Brooke Boswell – Director Home & Community Based Services
Waivers
Matt Keppler – LTC Government Relations Liaison
TennCare LTC Unit Staff
Telephone Numbers
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Patty Killingsworth (Chief of LTC) (615) 507- 6468
Pat Santel (Director of LTC) (615) 507-6964
Debbie Coleman, RN (PAE Mgr.) (615) 507-6964
Reba Hitchock, RN (PAE Supervisor) (615) 507-6979
Kaye Swindell, RN (PAE Supervisor) (615) 507-6976
Laurie Gibbs, RN (PAE Nurse) (615) 507-6981
Carol Harrison, RN (PAE Nurse) (615) 507-507-6026
Joy Foster, RN (PAE Nurse) (615) 507-6980
Harriet Cummings, RN (PAE Nurse-ICF, HCBS/MR)
(615) 507-6975
Kim Carroll (Billing & Claims Unit) (615) 507-6998
Glenda Davidson (Billing & Claims Unit) (615) 507-6944
What if a PAE/PASRR is denied?
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The Notice of Denial is issued when it is determined
that resident requires Specialized Services for MI/MR
The PAE with additional information can be
resubmitted within 30 calendar days of the receipt of
Notice of Denial.
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Or an Appeal of the denied PAE can be submitted
within 30 calendar days of the notice of denial
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The important thing is to respond to the denial within
30 days
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If the resident needs help contact
 Legal aid
 Ombudsman
The Appeal Process
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The resident, designated correspondent,
family, the ombudsman, a friend can appeal a
denied PAE
The appeal must be received within 30 days of
the receipt of the Notice of Denial
Appeal Process Continued
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Once an appeal of denial is received a
Hearing date is scheduled. The individual can
be represented at the hearing by anyone of
their choice
The hearing will be conducted at the nursing
facility if the applicant is admitted or if not
admitted, a place convenient to the
applicant.
ALJ Decision
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The Judge must have his written decision
within 90 days of receipt of the appeal letter
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The Nursing facility can not do an involuntary
discharge once an appeal has been received.
The NF must notify the resident/family they
may be responsible for payment of NF care if
judgment is against them.
Preadmission Screening and
Annual Resident Review
PASRR
Survey Process
State Survey Agency
CFR REQUIREMENTS
§483.20(m) “A nursing facility must not admit, on or
after January 1, 1989, any new resident with:
(i) Mental illness as defined in paragraph (m)(2)(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.
Survey Process
CFR REQUIREMENTS
(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 mental
retardation.
Survey Process
Intent of: §483.20(m)
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To insure that individuals with mental
illness and mental retardation receive the
care and services they need in the most
appropriate setting.
The statute mandates preadmission
screening for all individuals with mental
illness or mental retardation who apply to
Nursing Facilities regardless of the
applicant’s source of payment.
Survey Process
Intent of: §483.20(m) Exceptions
The exceptions for preadmission screening are:
 Residents who are readmitted to the facility.
 Residents who initially apply to a nursing facility
directly following a discharge from an acute care stay
are exempt if:
(a) Certified by a physician prior to admission to
require a nursing facility stay of less than 30 days
and;
(b) Require care at the nursing facility for the
same condition for which they were hospitalized.
Survey Process
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1.
2.
Probes the survey team will use to determine if the
facility is in compliance with this regulation.
Will place a portion of the residents (if any) who
have MI/MR on the survey sample.
Will review the PASRR, interview staff, review
records and make observations of the sampled
resident/s to determine if special activities were
recommended, if they have been care planned,
and if the care plan is being followed by staff.
Survey Process
§483.10(j) Visitation Rights
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Effective June 17, 2009: F-175 revisions
The facility must provide immediate access
to any representative of the Secretary of
HHS, the State, the resident’s individual
physician, the State LTC Ombudsman, or
the agencies responsible for the protection
and advocacy of {individuals with
developmental disabilities or mental
illness.}
Survey Process
§483.10(j) Visitation Rights
The facility cannot refuse to permit
residents to talk with surveyors,
Representatives of the Dept. of HHS,
The State, the State {Long Term Care}
ombudsman system and protection and
advocacy agencies for {individuals with
developmental disabilities or mental
illness} are not subject to visiting hour
limitations.
Resources for Crisis Intervention
The National Alliance on Mental
Illness (NAMI)
http://www.namitn.org/resources.htm
Health Plan Crisis Response
Service Contacts
AmeriChoice
Primary Contact:
Leigh Anne Dempsey, QI Specialist
8 Cadillac Drive, Suite 100
Brentwood, TN 37027
(615) 493-8984
[email protected]
Secondary Contact (please cc):
Hayley Clothier, Quality Manager
8 Cadillac Drive, Suite 100
Brentwood, TN 37207
(615) 493-9559
[email protected]
Volunteer State Health Plan (VSHP)
Julie Gascay
Mgr/ Clinical Services
423-535-6330
and/ or
Debbie Dukes
Clinical Director
423-535-7608
AMERIGROUP
Heather Baroni
Vice President of Behavioral Operations
Phone: 615-316-2423
E-mail: [email protected]