Screening for Mental Illness in Nursing Facility Applicants:
Understanding Federal Requirements
V. The PASRR Process
Table 1 (Appendix) provides detail and definitional sources for the elements of the PASRR program. All Medicaid recipients applying for new admission to a nursing facility must be screened to identify those suspected of having a mental illness. The Medicaid statute does not specifically require that all NF applicants be screened for mental illness. Rather, it requires that all applicants who have mental illness be screened for their need for NF services and specialized services to treat their mental illness. However, to determine the universe of nursing facility applicants suspected of having a mental illness, some form of screening must be conducted on all applicants. Regulations mandate this preliminary screening and refer to it as a Level I screening. Because Federal regulations provide no rules about the tools used or personnel involved in Level I screening, the screening may be conducted by nursing facilities, hospitals, physicians, or any other entity specified by the State's Medicaid program.
Patients who are admitted to an NF directly from a hospital after receiving acute inpatient care; who require NF services for the condition for which they received hospital care and whose attending physician has certified prior to admission to the NF that they are expected to stay in the nursing facility for less than 30 days are exempt from preadmission screening requirements. Patients being readmitted to a nursing facility or being transferred from one nursing facility to another are not considered new admissions and, thus, resident review requirements apply.
Applicants suspected of having a mental illness (who rated "positive" in the Level I screen) undergo a more extensive preadmission review called Level II screening. Level II screening requires an independent evaluation of applicants' physical and mental health status. Independent evaluators must not have any ties to nursing facilities, nor may they be part of a State Mental Health Authority (SMHA). The independent evaluator must verify whether the applicant has a serious mental illness. Applicants without serious mental disorders may be admitted to the nursing facility without further PASRR review.
A serious mental illness is defined as a mental disorder that may lead to a chronic disability and is diagnosable under the DSM-III-R other than dementia, unless the primary diagnosis is a major mental disorder. The disorder must have resulted in functional limitations in major life activities within the past 3 to 6 months. In addition, the applicant must experience at least one of the following: (1) psychiatric treatments more intensive than outpatient care or (2) significant disruption to the normal living situation requiring supportive services or intervention by housing or law enforcement personnel.
For applicants diagnosed with a serious mental illness, SMHAs must use the independent evaluation to determine whether the applicant requires the level of care offered by the nursing facility and whether specialized services are necessary to treat the applicant's mental illness. Applicants with SMI may be admitted only if they are determined to require the level of nursing care the facility provides. Applicants who do not need NF services cannot be admitted to the facility.
If it is determined that an applicant also needs specialized services to treat a mental illness, the State Medicaid agency ultimately is responsible for providing or arranging for the provision of those services. Congress authorized HHS to define specialized services through regulations. In turn, HHS published regulations defining specialized services as those "specified by the State" for the continuous and aggressive treatment of a nursing facility resident's mental illness. Thus, Federal law and regulations provide no specific definition of the specialized services that must be provided to nursing home residents with SMI. The mandate to provide such services extends only to those specialized services a State includes in its definition.
Furthermore, Medicaid statute requires nursing facilities to provide treatment and services "not otherwise provided or arranged for (or required to be provided or arranged for) by the State." This requirement is interpreted in regulations to include all "services of lesser intensity than specialized services." The absence of a definition of specialized services in either Federal law or regulations has resulted in considerable confusion about the services to be provided by States and those to be provided by nursing facilities. If a State chooses to limit its definition of specialized services to reduce the scope of this unfunded mandate, it shifts a greater burden onto nursing facilities to provide or arrange for psychiatric services.
Before the 1996 amendments (Public Law 104-315), individuals residing in nursing facilities were required to be screened for mental illness at least annually as if they were new admissions. Current law does not require that NF residents be screened on an annual basis for mental illness. Instead, the statute requires nursing facilities to report significant changes in a resident's mental condition promptly to the State Mental Health Authority. Regulations specify that SMHAs must conduct a Level II screen to evaluate such residents and determine if their placements continue to be appropriate and whether their specialized services needs have changed.
All NF residents determined by State Mental Health Authorities to require NF services may continue to reside there. Residents who do not need NF services may choose to continue residing in the facility only if they both need specialized services and have continuously lived in a nursing facility for at least 30 months. All other residents with mental illness must be discharged. States must provide specialized services to residents found to need such services, regardless of whether they may stay in the nursing facility.
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