PASRR Overview and FAQ - Maximus

PASRR LEVEL I SCREEN USER GUIDEDETERMINATION FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY,AND OTHER RELATED CONDITIONS

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PASRR Overview and FAQ

APPLICANT NAME: The consumer’s name should appear at the top of each page of the form1. SUBMITTING HOSPITAL/AGENCY INFORMATION

HOSPITAL/AGENCY NAME Clearly print the name of the facility where the consumer is locatedwhen the screen is filled out, not the expected placement.

DATE Clearly print the current date.FAX NUMBER Clearly print the number to which the Level I Determination Letter

should be faxed.PHONE NUMBER Clearly print the phone number at which the person filling out the

form can be reached if GHS has questions or needs more information.PRINT NAME/LICENSURE/TITLE OF PERSONCOMPLETING FORM

Clearly print the name and title/licensure of the person completingthe screen.

Per the DHHS PASRR manual, the Level I Screen may be completed byhospital discharge planners, licensed social workers, registeredprofessional nurses, psychologists, physicians and professional NFstaff. The screen must be completed and signed by the same person.

2. CONSUMER INFORMATIONIf the form does not include all identifying information, the screen cannot be processed.

LAST NAME, FIRST NAME, MIDDLE INITIAL Clearly print the consumer’s full name in the format designated.DATE OF BIRTH Clearly print the consumer’s date of birth.SOCIAL SECURITY NUMBER Clearly print the consumer’s Social Security number.MAINECARE NUMBER Clearly print the consumer’s MaineCare ID number, if applicable.MEDICARE NUMBER Clearly print the consumer’s Medicare ID number, if applicable.OTHER PAYER SOURCE Clearly print the consumer’s additional payer names and ID numbers,

if applicable.HOME STREET ADDRESS Clearly print the consumer’s home address street name.TOWN, STATE, ZIP CODE Clearly print the consumer’s home town, state, and zip code.PHONE Clearly print the consumer’s home telephone number.

3. EMERGENCY CONTACT INFORMATIONNAME Clearly print the name of the consumer’s emergency contact.RELATIONSHIP Clearly print the type of relationship between the consumer and their

emergency contact (e.g. parent, sibling, POA, etc.)

GUARDIAN Y N Indicate whether the consumer’s emergency contact hasguardianship.

POA Y N Indicate whether the consumer’s emergency contact has Power ofAttorney.

MAILING ADDRESS Clearly print the contact’s mailing address street name.TOWN, STATE, ZIP CODE Clearly print the contact’s mailing address town, state, and zip code.PHONE Clearly print the contact’s telephone number.

4. ANTICIPATED OR CURRENT NURSING FACILITYFACILITY NAME (IF UNKNOWN ENTER “TBD”) The admitting NF does not need to be identified before completing

the Level I screen. If unknown, enter “TBD”PHONE Clearly print the facility’s telephone number.FACILITY STREET ADDRESS Clearly print the facility’s street address.TOWN, STATE, ZIP CODE Clearly print the facility’s street address town, state, and zip code.ESTIMATED NUMBER OF DAYS IN FACILITY Clearly print the estimated number of days to be spent in the facility.REASON FOR STAY

SHORT TERM REHAB, SKILLED CARE, RESPITEIndicate the reason for stay.

Remember that Level of Care (LOC) precedes PASRR:


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PERMANENT PLACEMENT (LTC) If the consumer is being discharged to a swing bed, a PASRR Level I isnot required. If/when the patient is being discharged to a NF bed fromthe swing unit, submit the Level I screen.

If the consumer is being discharged to an acute hospital setting andnot a SNF/NF unit, a Level I screen is not needed. If/when the patientis being discharged to a NF bed from the hospital, submit the Level Iscreen.

5. DEMENTIA DIAGNOSIS AND/OR SUBSTANCE RELATED DISORDER5.1 DOES THE INDIVIDUAL HAVE A DEMENTIA DIAGNOSIS? Y N Indicate whether the consumer has a diagnosis ofdementia.

IF YES, DSM CODE (# REQUIRED) __________________ Clearly print the DSM Code. (Required)

Dementia is listed In DSM IV but it is considered a cognitive disorder, not a serious mental illness for the purposes of PASRR. InDSM V, dementia falls under the category of major neurocognitive disorder (NCD,) and is again not a serious mental illness for thepurposes of PASRR. NCD as a term replaces dementia. NCD is defined by the following:

• There is evidence of substantial cognitive decline from a previous level of performance in one or more of the domainsoutlined above based on the concerns of the individual, a knowledgeable informant, or the clinician; and a decline inneurocognitive performance, typically involving test performance in the range of two or more standard deviations belowappropriate norms (ie, below the third percentile) on formal testing or equivalent clinical evaluation.

• The cognitive deficits are sufficient to interfere with independence (i.e., requiring minimal assistance with instrumentalactivities of daily living).

• The cognitive deficits do not occur exclusively in the context of a delirium.

• The cognitive deficits are not primarily attributable to another mental disorder (e.g., major depressive disorder,schizophrenia).

When a diagnosis of dementia and mental illness co exist, federal regulations suggest that PASRR programs may not simply acceptreports regarding the primacy of dementia over the mental illness without question. To exclude an individual from PASRRactivities due to dementia, evaluators must gather evidence to determine that it is so advanced that the individual would nolonger benefit from specialized MH services. Diagnosis alone is not sufficient without the supportive description.

IF YES, IS DEMENTIA THE PRIMARY DIAGNOSIS? Y N Indicate whether the diagnosis of dementia is primary.IF DEMENTIA IS PRIMARY, PROVIDE THE DATE OF THE DIAGNOSIS AND THE NAME OF THE CLINICIAN: Clearly print the date thedementia diagnosis was made and the name of the clinician who made the determination

When co morbid dementia and mental illness are apparent, presenting and collateral information is vital to determining the levelof dementia, and the collection of evidence by the facility to support the primacy/secondary nature of dementia expedites thisprocess.

The referral source can avoid unnecessary Level II Screens and the delays associated with them if they can provide clear evidenceof a dementia diagnosis. It is the facility’s cooperation and assistance that usually make the difference between the shorter,typical turn around times, and longer times for PASRR review.

Elements of the presence and progression of dementia to consider: What is the current level of dementia (MILD MODERATESEVERE)? Is the consumer on any medications for treatment of dementia, e.g. Aricept, Nameda, etc.? Is this medicationprescribed by a psychiatrist or an MD? Is the consumer going to be placed on a locked dementia unit? If there have been


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psychiatric hospitalizations, have they been for treatment of dementia? Before the onset of dementia, did the person havemental health services and/or treatment? Before the onset of dementia, did the person function in the community – work, raisea family, etc.?5.2 DOES THE INDIVIDUAL HAVE A SUBSTANCE RELATED DISORDER? Y N Indicate whether the consumer has a substancerelated disorder.

Signs and symptoms which may suggest a major mental illness can be the result of a variety of reasons. Major mental disorder isonly one cause. Symptoms may be associated with substance related disorders that include disorders related to drug abuse(including alcohol), to the side effects of medication and to toxin exposure, and can cause delirium, dementia, depression,psychotic disorders, personality changes and other symptoms that appear to be a major mental disorder.

This section of the screen is meant to capture all signs and symptoms that suggest mental illness regardless of cause.

DIAGNOSIS (Dx): Clearly print the diagnosis

PLEASE MARK THIS BOX TO INDICATE IF THIS SCREEN IS FOR A CHANGE IN CONDITIONMark the box if this screen is for a Change in Condition (CIC).

This box should be marked if a time limited waiver previously given has expired and an extension is necessary or if the consumerwill be continuing to stay at the facility long term. will determine if, based on the Level I screen, a CIC requires a LevelII assessment.

Every time a person has a significant change MDS, a new Level I screen should be submitted so that can reviewand determine if a Level II Assessment is required.

A CIC for medical reasons only does not meet PASRR criteria and a Level II does not need to be completed.

A CIC for psychiatric hospitalization due to mental illness does meet criteria and a Level II will be completed.

Referring facilities will be notified of the outcome of a CIC referral.


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APPLICANT NAME: The consumer’s name should appear at the top of each page of the form6. MENTAL ILLNESS (MI)

6.1 HAS THE INDIVIDUAL EVER BEEN DIAGNOSED WITHOR IS THERE A SUSPICION OF AMENTAL ILLNESS?Y N

A family reported finding does not qualify as a documented diagnosis.Only include diagnoses documented by a medical practitioner in themedical record. (Note that determinations cannot be made basedsolely on medications prescribed.)

Even if there is no MI diagnosis, the rest of the prompts must still befilled out because some consumers with MI do not yet have adiagnosis in their medical record reflecting that condition.

The questions on the form are designed so that the screener canquery the record and the individual to determine whether anyindicators of a potential MI exist even in the absence of a knowndiagnosis.

Facilities should have a low threshold for referral to PASRR so thatGoold Health Systems may exercise their expert judgment aboutwhen a Level II evaluation is needed.

6.2 DIAGNOSIS (Dx) OR SUSPECTED MENTAL ILLNESS Clearly print the consumer’s diagnosis. Use this space to entersuspected mental illness as well.

6.3 HOW LONG HAS THE INDIVIDUAL HAD THISDIAGNOSIS?

If exact dates are unknown, provide approximate dates from theconsumer or the caregiver.

6.4 DSM CODE (NUMBER REQUIRED) Clearly print the DSM Code. (Required)6.5 DOES THE INDIVIDUAL HAVE A SUSPECTEDMENTALILLNESS AS EVIDENCED BY ANY OF THE FOLLOWING:Y N INABILITY TO COMMUNICATE EFFECTIVELYWITH OTHERSY N INABILITY TO COMPLETE SIMPLE TASKSUNASSISTEDY N SERIOUS DIFFICULTY INTERACTINGWITHOTHERS APPROPRIATELYY N DANGER TO SELF OR OTHERS, AGGRESSIVE,ASSAULTIVE, SUICIDALY N FREQUENTLY ISOLATES OR AVOIDS OTHERS

OR EXHIBITS SIGNS THAT SUGGEST SEVEREANXIETY OR FEAR OF STRANGERS

Y N OTHER MAJOR MENTAL HEALTH SYMPTOMSTHAT HAVE EMERGED OR WORSENED AS A RESULT OFRECENT LIFE CHANGES; INDIVIDUAL NOW HAS ONGOINGSYMPTOMS

Identify whether the individual exhibited any of the followingsymptoms or behaviors currently or within the last 6 months; indicatewhether it is a baseline behavior.

This section of the screen captures key symptoms or behavioralindicators. When the information required on a Level I Screen is notyet part of a consumer’s medical record, the Level I screener isrequired to gather the required information from the consumerand/or the consumer’s caregivers.

Absence of disability related information in the medical record doesnot constitute the proof of absence of disability indicators.

6.6 DID THE INDIVIDUAL HAVE AN INTERVENTION DUETO AMENTAL ILLNESS IN THE PAST 2 YEARS, SUCH AS:Y N HOSPITALIZATION FOR PSYCHIATRIC CAREY N SUPPORTIVE SERVICES AT HOME (DAILYLIVING SUPPORT SERVICES/DLSS)Y N HOUSING OR LAW ENFORCEMENTINTERVENTIONY N RESIDENTIAL TREATMENT (PNMI LEVEL OF

History over the past 2 years is important due to the cyclical nature ofmental illness.

As such it is important that the screener obtain information from theindividual, caregivers, or others who know the patient well.

Significant life disruption or major treatment episodes within the past2 years might include when the mental illness exacerbated to theextent that critical resource adjustments (such as increased case


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CARE)Y N INTENSIVE COMMUNITY SUPPORTS (CASEMANAGEMENT SERVICES/CI/ACT)

management services, increased monitoring, etc.) would have beenindicated.

7. NEXT STEPSANY “YES” RESPONSE FOR QUESTIONS (6.1), (6.5) OR (6.6) MEETS PASRR CRITERIA FOR THE PRESENCE OF MENTAL ILLNESS OR THAT THE PRESENCE OF MENTAL ILLNESS IS SUSPECTED. FAX THIS ENTIRE FORM TO MAXIMUS ASCEND MAXIMUS ASCEND WILL DETERMINE WHETHER A LEVEL II IS NECESSARY.

IF THE RESPONSES TO THE ABOVE QUESTIONS ARE ALL `NO' ANDTHERE IS NO MENTAL ILLNESS DIAGNOSIS, OR ONLY A DEMENTIADIAGNOSIS, FAX THIS FORM TO THE NURSING FACILITY PRIOR TODISCHARGE AND NOT TO GHS. PASRR SCREENING MATERIAL IS TO BEKEPT IN THE CONSUMER'S ACTIVE FILE AND MAY BE SUBJECT TOAUDIT.

If this screen is submitted, it will receive one of the followingautomatic fax responses:

“As this Screen was submitted with no mental health diagnosisand all responses to the questions in 6 thru 10 are ‘no’, noreview is needed. Please send this Screen to the facility uponthe patient’s discharge so the facility can keep a copy in theresident’s chart. No determination letter will be issued from

.”

“As this Screen was submitted with a dementia diagnosis andno mental health diagnosis and all responses to the questionsin 6 thru 10 are ‘no’, no review is needed. Please send thisScreen to the facility upon the patient’s discharge so the facilitycan keep a copy in the resident’s chart. No determinationletter will be issued from .”


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APPLICANT NAME: The consumer’s name should appear at the top of each page of the form8. INTELLECTUAL DISABILITY (ID)

An applicant is considered to have an intellectual disability (ID), autism or a pervasive developmental disorder (PDD) if the criterialisted below are met OR the individual has previously been found eligible for services based on a diagnosis of an ID, autism or aPDD by DHHS. Documentation is not necessary to support the criterion as long as the individual is suspected to meet the criterionbased on observations and knowledge about the individual.8.1 HAS THIS INDIVIDUAL EVER BEEN DIAGNOSED WITHOR IS THERE A SUSPICION OF AN INTELLECTUALDISABILITY, AUTISM OR A PDD? Y N IF YES,PLEASE SPECIFY:

Indicate whether the consumer has been diagnosed with anintellectual disability, autism, or a PDD. If yes, specify.

ANSWER ALL OF THE QUESTIONS ON THE REST OF THE PAGE EVEN IF THE RESPONSE ABOVE IS “NO”8.2 THE INDIVIDUAL HAS IMPAIRMENTS IN ADAPTIVEBEHAVIOR THAT SHOW A SIGNIFICANT LIMITATION INMEETING THE STANDARDS OF THE FOLLOWING FORHIS/HER AGE AND CULTURAL GROUP:

MATURATIONLEARNINGPERSONAL INDEPENDENCESOCIAL RESPONSIBILITY

Y N

Indicate whether the consumer has impairments in adaptive behaviorthat show significant limitation in meeting the standards for his/herage and cultural group.

Does the individual have presenting evidence of ID that has not beendiagnosed?

8.3 THE INDIVIDUAL HAS IMPAIRMENTS IN ADAPTIVEBEHAVIOR THAT SHOW SUBSTANTIAL FUNCTIONALLIMITATION IN 3 OR MORE OF THE FOLLOWING AREASOF MAJOR LIFE ACTIVITIES,WHICH ARE NOT RELATEDTO THE NORMAL AGING PROCESS.

CHECK ALL AREAS OF SUBSTANTIAL FUNCTIONALLIMITATION WHICH WERE PRESENT PRIOR TO AGE 18ANDWERE DIRECTLY THE RESULT OF THE ID.

SELF CAREUNDERSTANDING/USE OF LANGUAGELEARNINGMOBILITYSELF DIRECTIONCAPACITY FOR INDEPENDENT LIVING

WERE 3 OR MORE LIMITATIONSWERE NOTED?

Rosa’s Law changed references in federal law to ‘mental retardation’to references to an ‘intellectual disability’, and changed references toa ‘mentally retarded individual’ to references to ‘an individual with anintellectual disability’.

ID only applies to individuals with a diagnosis or suspicion of ID. Itdoes not apply to dementia, mental illness, or medical conditions thatare not related conditions to intellectual disability (e.g. hip fractures,pneumonia, etc.)

One of the key challenges is to confirm that lowered cognitive levelsoccurred during the developmental period and are not a result ofother medical issues, e.g. stroke, TIA, or accidents/injuriesexperienced during adulthood.

Federal law requires PASRR evaluation if the consumer is known tohave or suspected of having ID, even when testing or documentationis not available to confirm conclusively the diagnosis.

8.4 SERVICES: HAS THE INDIVIDUAL RECEIVED SERVICESFROM A DEVELOPMENTAL SERVICES AGENCY IN THEPAST OR BEEN FOUND ELIGIBLE FOR SERVICES BY DHHSBASED ON A DIAGNOSIS OF AN ID, AUTISM OR A PDD?Y N

It is the obligation of the person completing the PASRR Screen to fill ineach response as accurately as possible. If the clinical record does notclearly state the answers to the questions on the Screen, the hospitalstaff or nursing facility must ask the consumer and/or guardian orPOA and document the response.

IF YES, PLEASE IDENTIFY DHHS REGION & CASEWORKER: Clearly print the DHHS region and Caseworker’s name. Include contactinformation if available.

8.5 FACILITIES: HAS THE INDIVIDUAL EVER BEEN ARESIDENT OF A DEVELOPMENTAL DISABILITY FACILITYOR ICF/IID? Y N IF YES, PLEASE IDENTIFYFACILITY:

Indicate whether the consumer has ever been a resident of Pineland,a resident of a Residential Care facility for individuals with adevelopmental disability or an ICF/IID (Intermediate Care Facility forIndividuals with an Intellectual Disability). If yes, clearly print thename of the facility. Include contact information if available.


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9. NEXT STEPSWERE ANY OF THE RESPONSES ABOVE “YES”?ANY “YES” RESPONSE FOR QUESTIONS (8.1, 8.2 AND 8.3) OR (8.4) OR (8.5) MEETS PASRRCRITERIA FOR DIAGNOSIS OR SUSPICION OF ID, AUTISM OR PDD. FAX THIS ENTIRE FORM TO

. WILL DETERMINE WHETHER A LEVEL II IS NECESSARY..IF THE RESPONSES TO THE ABOVE QUESTIONS ARE ALL `NO' AND THERE IS NO MENTAL ILLNESS DIAGNOSIS, OR ONLY A DEMENTIA DIAGNOSIS, FAX THIS FORM TO THE NURSING FACILITY PRIOR TO DISCHARGE AND NOT TO MAXIMUS ASCEND. PASRR SCREENING MATERIAL MAY BE SUBJECT TO AUDIT.


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APPLICANT NAME: The consumer’s name should appear at the top of each page of the form10. OTHER RELATED CONDITIONS (ORC)

Persons with related conditions means individuals who have a severe, chronic disability that meets all of the following conditions:is attributed to epilepsy or cerebral palsy; or any other condition, other than mental illness, found to be closely related to mentalretardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that ofmentally retarded persons, and requires treatment or services similar to those required for these persons; and it is manifestedbefore the person reaches age 22; and it is likely to continue indefinitely; and it results in substantial functional limitations inthree or more of the following areas of major life activity: self care, understanding and use of language, learning, mobility, selfdirection, and capacity for independent living.10.1 HAS THE INDIVIDUAL BEEN DIAGNOSED WITH ORSUSPECTED OF HAVING ONE OR BOTH OF THEFOLLOWING CONDITIONS?Y N CEREBRAL PALSYY N EPILEPSY

Indicate whether the consumer has been diagnosed with or issuspected of having cerebral palsy and/or epilepsy.

10.2 DOES THE INDIVIDUAL HAVE ANY OTHERCONDITION, OTHER THAN A SERIOUS MENTAL ILLNESSTHAT:

Is closely related to an intellectual disability (ID)Results in impairment of general intellectualfunctioning or adaptive behavior similar to that ofindividuals with an IDRequires treatment or services similar to thoserequired for individuals with an ID

Y N IF YES, PLEASE SPECIFY:

Although federal definition of ORC includes disability related toCerebral Palsy and Epilepsy, it does not exclude any diagnosis orcondition categorically except for serious mental illness (SMI). It doesnot apply to dementia, intellectual disability, or medical conditionsthat are not related conditions, (e.g. hip fractures, pneumonia, etc.)

Examples of related conditions include, but are not limited to:Traumatic Brain Injury, Fetal Alcohol Syndrome, Muscular Dystrophy,Down Syndrome, Stroke, TIA, Spina Bifida, Seizure Disorder, etc.

IF ALL OF THE QUESTIONS ABOVE RESULTED IN “NO” STOP HERE AND GO TO SECTION 11 ON THIS PAGE.

If more than one condition is “YES”, answer the remaining questions on this page for each condition.One ORC form may be submitted with separate responses for each condition.

10.3 DID THE ORC MANIFEST BEFORE THE INDIVIDUALREACHED THE AGE OF 22?Y N

Indicate whether the ORC manifested before age 22.

10.4 IS THE ORC LIKELY TO CONTINUE INDEFINITELY?Y N

Indicate whether the ORC is likely to continue indefinitely.

10.5 CHECK ALL AREAS OF SUBSTANTIAL FUNCTIONALLIMITATION WHICH WERE PRESENT PRIOR TO AGE 22ANDWERE DIRECTLY THE RESULT OF THE ORC.

SELF CAREUNDERSTANDING/USE OF LANGUAGELEARNINGMOBILITYSELF DIRECTIONCAPACITY FOR INDEPENDENT LIVING

Indicate all areas of substantial functional limitation which were adirect result of the ORC and were present before age 22.

It is the obligation of the person completing the PASRR Screen to fill ineach response as accurately as possible. If the clinical record does notclearly state the answers to the questions on the Screen, the hospitalstaff or nursing facility must ask the consumer and/or guardian orPOA and document the response.

10.6WERE 3 OR MORE LIMITATIONS NOTED?

Indicate whether 3 or more or 2 or less limitations were noted in theprevious section regarding substantial functional limitation(s) directlyresulting from the ORC prior to the age of 22.

11. NEXT STEPSWERE ANY OF THE RESPONSES ABOVE “YES”? ANY “YES” RESPONSE FOR QUESTIONS (10.1) OR (10.2) AND (10.3, 10.4, 10.6) MEETS PASRR CRITERIA FOR THE DIAGNOSIS OF ORC. FAX THIS ENTIRE FORM TO MAXIMUS ASCEND MAXIMUS ASCEND WILL DETERMINE WHETHER A LEVEL II IS NECESSARY.

IF THE RESPONSES TO THE ABOVE QUESTIONS ARE ALL `NO' AND THERE IS NO MENTAL ILLNESS DIAGNOSIS, OR ONLY ADEMENTIA DIAGNOSIS, FAX THIS FORM TO THE NURSING FACILITY PRIOR TO DISCHARGE AND NOT TO


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12. ATTESTATIONI ATTEST THAT I HAVE SPOKEN DIRECTLY WITHTHE APPLICANT AND/OR GUARDIAN OR POAWHILE FILLING OUT THIS FORM.

Facilities must perform due diligence to gather basic informationsufficient to indicate on the Screen whether or not a suspicion of aPASRR condition may be present; this information may be found inthe record and/or obtained through query of the consumer or theconsumer’s medical designee.

PASRR is a person centered process that promotes quality of life andplacement success. The consumer and/or legal representative mustbe involved in the process. These individuals may assist in identifyingpreviously unreported MI/ID/ORC.

The State of Maine DHHS requires that the person filling out the formsign to attest that they have spoken directly with the consumerand/or guardian or POA as part of gathering information necessary tocomplete this form.

PLEASE SUBMIT ALL PAGES, INCLUDING THE SIGNED ATTESTATION.

Keep all PASRR Screening materials in the consumer’s Active file asPASRR screens may be subject to audit.

If you need further assistance with complete the Level I Screen form or have general questions about

PASRR, please call MAXIMUS Ascend at .

Maine ASA Fax #:

PASRR Overview and FAQ - Maximus

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