BEHAVIORAL HEALTH PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) FOR SERIOUS MENTAL ILLNESS

(1) This chapter describes the behavioral health (BH) preadmission screening and resident review (PASRR) program and a person's rights relating to PASRR. For admission screening regulations for people with intellectual disabilities or a related condition, see chapter 388-834 WAC.

(2) The goals of the PASRR process are to ensure that people:

(a) Who have a mental illness, serious mental illness, intellectual disabilities, or a related condition are not inappropriately admitted to a medicaid-certified nursing facility; and

(b) Who are appropriately admitted to a nursing facility receive the recommended specialized services for their BH PASRR condition.

(3) For PASRR rules relating to nursing facility compliance, see WAC 388-97-1910 through 388-97-2000.

The following definitions apply to this chapter:

"Behavioral health notice of determination (NOD)" means a written notice to a person that a behavioral health PASRR evaluation and determination has been made regarding the person's nursing facility stay, including the person's existing or suspected behavioral health diagnosis, and whether the person may need or benefit from behavioral health services. This is provided to facilities to document that the behavioral health (BH) PASRR evaluation is complete and the level 2 evaluation or invalidation is pending. The NOD indicates that BH PASRR requirements have been met prior to nursing facility admission.

"Behavioral health PASRR determination" means a written notice from the behavioral health PASRR evaluator that indicates completion of either a level 2 evaluation or a level 2 invalidation.

"Behavioral health PASRR evaluator (BH PASRR evaluator)" means an authority-appointed, licensed mental health provider who provides behavioral health PASRR level 2 evaluations and PASRR determinations.

"Behavioral health PASRR level 2 evaluation" means an evaluation that is completed when a possible behavioral health (BH) PASRR condition is identified by the PASRR level 1 screening. The BH PASRR level 2 evaluation determines whether the person has credible suspicion of a BH PASRR condition, needs nursing facility care, and may need specialized services while in the nursing facility.

"Behavioral health PASRR level 2 invalidation" means the form (HCA 82-0034) used to determine that a person residing in a nursing facility or a nursing facility applicant who has been identified as positive on a PASRR level 1 screening does not require specialized service recommendations.

"Categorical determination" means a determination by a behavioral health or developmental disabilities administration (DDA) PASRR evaluator that a person may be admitted to a nursing facility on a temporary basis.

"Credible suspicion (of a behavioral health PASRR condition)" means a person exhibits or is reliably reported to exhibit one or more functional limitations, or there is some evidence that a serious mental illness may exist due to symptoms, behaviors, or other indicators. This is also considered a "known or suspected" condition.

"Developmental disabilities administration (DDA)" means the division of the department of social and health services that provides support to people with intellectual and developmental disabilities.

"Exempted hospital discharge" means the process by which a person may be admitted to a nursing facility without a behavioral health PASRR level 2 evaluation, due to the anticipated length of stay being 30 days or fewer, even though the person may have a behavioral health PASRR condition.

"Interfacility transfer" means a person who is transferred from one nursing facility to another nursing facility, with or without an intervening hospital stay. The person is not considered a new admission and does not need a preadmission screening.

"Mental illness" means a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet the diagnostic criteria specified within the current Diagnostic and Statistical Manual of Mental Disorders (DSM).

"Minimum data set" means a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in medicare or medicaid.

"PASRR condition" means a mental illness, serious mental illness, intellectual or developmental disability, or related condition, as defined in 42 C.F.R. § 483.102(b) or successor rule or governing statute.

"PASRR level 1 screening" means a screening that is completed when a person:

(a) Is referred to a medicaid-certified nursing facility by a physician, hospital, or other referring entity; or

(b) Residing in a nursing facility experiences a significant change in condition.

"Preadmission screening and resident review (PASRR) process" or "PASRR process" means the process required by federal law to determine if admission to a nursing facility is appropriate for a person who has a BH PASRR condition, and if so, to determine whether specialized services are necessary during the nursing facility stay.

"Referent" means both the licensed medical professional who completes a PASRR level 1 screening form and their employer or organization.

"Serious mental illness" means, for the purposes of this chapter, any known or suspected mental illness that:

(a) Resulted in functional impairment, which substantially limits one or more major life activities such as employment, school, or social relationships; or

(b) Would have caused an impairment absent treatment or support services.

"Significant change in condition" means a deterioration or improvement in the physical or mental condition of a person with a PASRR condition, such that:

(a) The person may reasonably require new, different, or fewer specialized services;

(b) The person's care plan requires changes regarding a known or suspected behavioral health PASRR condition; or

(c) Significant improvements have led to the possibility of community placement as a reasonable consideration for the person.

"Specialized services" means services, as described in 42 C.F.R. § 483.120 or successor laws or governing statute and provided or arranged for by the authority or department of social and health services, that are in addition to nursing facility care. These services enable a person residing in a nursing facility with a behavioral health PASRR condition to preserve or increase their functional status, self-determination, and independence.

(1) Any person referred to a medicaid-certified nursing facility, regardless of whether the person has private insurance, must have a behavioral health preadmission screening and resident review (PASRR) level 1 screening and determination prior to nursing facility admission.

(2) For new nursing facility admissions, a hospital or primary care provider, as defined in RCW 74.09.010, is a referring provider and is responsible for initiating the behavioral health PASRR level 1 screening. For hospital-specific regulations, see WAC 246-320-226.

(3) For existing nursing facility residents, the behavioral health level 1 screening may be initiated by a licensed medical professional.

The behavioral health (BH) preadmission screening and resident review (PASRR) process must include the following steps:

(1) A referring provider, such as a hospital, physician, or other licensed medical professional, must conduct a BH PASRR level 1 screening to identify whether there is a known or suspected BH PASRR condition;

(2) The referent conducting the screening must use the standardized form and guidelines developed by the department of social and health services' PASRR program to conduct the BH PASRR level 1 screening;

(3) The developmental disabilities administration (DDA) division or authority-appointed behavioral health (BH) PASRR evaluator, or both, as appropriate, must make the BH PASRR determination.

(a) DDA provides determinations for an intellectual disability or related condition (ID/RC);

(b) The authority provides determinations for a serious mental illness; and

(c) If a person shows indicators of both a serious mental illness and ID/RC, the referent must provide the PASRR level 1 screening form to both DDA and the authority.

(4) Based upon the BH PASRR level 1 screening, a person who has a known mental illness, or a person with a suspected serious mental illness must undergo an evaluation; and

(5) The BH PASRR determination results in either a BH PASRR level 2 invalidation or a BH PASRR level 2 evaluation. A BH PASRR level 2 evaluation must include the following information:

(a) Whether the person has a mental illness, or has a suspected serious mental illness;

(b) For a person who has a BH PASRR condition, whether nursing facility placement is appropriate given their behavioral health PASRR condition; and

(c) If nursing facility placement is appropriate:

(i) Whether the person requires specialized services while residing at the nursing facility; and

(ii) Which specialized services would be beneficial to the person while residing there.

(1) If a person's behavioral health (BH) preadmission screening resident review (PASRR) level 1 screening does not identify a known or suspected BH PASRR condition, a nursing facility may directly admit the person, and the person's BH PASRR level 1 documentation must become part of their medical record.

(2) If a BH PASRR level 1 screening indicates a known or suspected BH PASRR condition, the referent must forward the screening to the behavioral health (BH PASRR) evaluator for a BH PASRR determination before the person's hospital discharge. For nursing facility-specific guidelines, see WAC 388-97-1915.

(a) The BH PASRR evaluator must make a BH PASRR determination prior to nursing facility admission, unless the person meets the criteria for an exempted hospital discharge as described in subsection (8) of this section or meets the definition of an interfacility transfer.

(b) The nursing facility must:

(i) Verify the referring hospital or provider completed the person's BH PASRR level 1 screening or deny admission until that screening is complete; and

(ii) Verify the person has a complete BH PASRR determination when the BH PASRR level 1 screening indicates the person may have a BH PASRR condition.

(3) A person must have, at a minimum, either a completed BH PASRR level 2 invalidation or a BH notice of determination (NOD) before admission to a nursing facility to indicate completion of a BH PASRR determination.

(4) The BH PASRR evaluator must provide the:

(a) BH NOD to the discharging hospital and if possible, the admitting nursing facility; and

(b) BH PASRR level 2 evaluation, once completed, to:

(i) The person evaluated and their legal representative; and

(ii) The admitting or retaining nursing facility.

(5) The BH PASRR level 2 evaluation must include:

(a) Whether a nursing facility level of service is appropriate based on the person's behavioral health needs; and

(b) Recommendations for specialized services, if necessary.

(6) A BH NOD from the BH PASRR evaluator is only required if documentation of the final BH PASRR determination is not complete prior to the person's hospital discharge. For developmental disabilities administration-specific PASRR requirements for a person with an intellectual disability or a related condition (ID/RC), see WAC 388-97-1910 through 388-97-2000.

(7) The nursing facility must deny admission until the person's BH PASRR determination is completed, unless:

(a) All the criteria are met for an exempted hospital discharge; and

(b) The referring facility documents them on the BH PASRR level 1 screening.

(8) The criteria for exempted hospital discharge are:

(a) The nursing facility admits the person directly from a hospital after the person received acute inpatient care;

(b) The person requires nursing facility services for the same condition for which the person received hospital care; and

(c) The person's attending physician certifies on the BH PASRR level 1 screening the person is likely to require nursing facility services for 30 days or fewer.

(9) The nursing facility must decline admission to any person whose BH PASRR determination indicates that the person does not require nursing facility services or that nursing facility placement is otherwise inappropriate.

(10) The nursing facility must coordinate proactively with BH PASRR evaluators to minimize duplicate assessments and to ensure continuity of care for nursing facility residents who have a BH PASRR condition.

(1) A behavioral health preadmission screening and resident review (BH PASRR) evaluator may categorically determine that specialized services are not needed for the following types of admission:

(a) A protective services stay of seven days or fewer;

(b) Respite in a nursing facility for 30 days or fewer.

(2) A BH PASRR evaluator must make categorical determinations for behavioral health PASRR admissions.

As part of a behavioral health preadmission screening and resident review (PASRR) level 2 evaluation, the behavioral health (BH) PASRR evaluator must review the person's medical records and speak with the person and others who have relevant information. The BH PASRR evaluator must determine whether:

(1) The person has a PASRR condition. If the BH PASRR evaluator suspects a person has an intellectual disability or related condition (ID/RC), the referent must submit the PASRR level 1 screening form to the ID/RC team;

(2) Nursing facility admission is appropriate to meet the person's needs; and

(3) The person requires specialized services while at the nursing facility.

(1) Before a person's admission, the nursing facility must ensure the behavioral health (BH) preadmission screening and resident review (PASRR) level 1 screening is complete and accurate.

(2) If the BH PASRR level 1 screening identifies a possible PASRR-eligible condition:

(a) The person's record must include the final BH PASRR determination; and

(b) The nursing facility must ensure that the recommended specialized services, if indicated, are incorporated into the person's care plan.

(3) The nursing facility must complete a new BH PASRR level 1 screening using the department of social and health services' standardized form and submit the form to the regional BH PASRR evaluator point of contact, if needed, based on the person's change in condition, behaviors, or mood, or when indicated by a minimum data set (MDS) review.

(1) People who have been evaluated by a behavioral health (BH) preadmission screening and resident review (PASRR) evaluator have the right to an administrative hearing to dispute the following determinations by the BH PASRR evaluator:

(a) Nursing facility placement is not appropriate to meet the person's needs; or

(b) The person does not require specialized services.

(2) Any decision rendered by the office of administrative hearings (OAH) is an initial decision appealable to the authority's board of appeals.

(3) For additional information regarding PASRR appeals, see WAC 388-97-0140.