SCREEN/PASRR Frequently Asked Questions (FAQ) Revised June 2013

Important Notes:

• The Office of Mental Retardation and Developmental Disabilities (OMRDD) has changed its name to the Office for People With Developmental Disabilities (OPWDD). All references to OMRDD in SCREEN Form DOH-695 (2/2009) and the Instruction Manual for SCREEN Form DOH-695 (2/2009) should be replaced with OPWDD. All references to mental retardation/developmental disability (MR/DD) should be replaced with intellectual disability/developmental disability (ID/DD). All references to Developmental Disabilities Services Offices (DDSO) should be replaced with Developmental Disabilities Regional Offices (DDRO).
• The Health Provider Network (HPN) is now referred to as the Health Commerce System (HCS). All references to the HPN in the Instruction Manual for SCREEN Form DOH-695 (2/2009) should be replaced with HCS.
• CMS has replaced MDS 2.0 with MDS 3.0 effective October 1, 2010. All references to MDS 2.0 should be replaced with MDS 3.0.

Screener Qualifications

Q1. How do I know if I am qualified to complete SCREEN Form: DOH-695 (2/2009)?

A1. Only persons who have completed the New York State Department of Health (NYSDOH) approved SCREEN training, offered in May 2009 or thereafter, are qualified to complete SCREEN Form: DOH-695 (2/2009). Qualified SCREENERS can be identified by their ten digit identification number.

Q2. I was trained and qualified to complete a previous version of SCREEN Form: DOH-695. Will the NYSDOH "grandfather me in" and allow me to complete SCREEN Form: DOH-695 (2/2009)?

A2. No, you will not be "grandfathered in." Refer to Dear Administrator Letters DRS/DAL 09-03 and DAL 09-06.

Q3. Who can complete the SCREEN?

A3. Title 10 New York Compilation of Codes Rules and Regulations (10 NYCRR) Section 400.11 states, "the SCREEN shall be completed by a professional with demonstrated skills in assessing psychosocial situations, including but not limited to social work and discharge planning professionals, who has successfully completed a training program in patient case mix screening approved by the department to train individuals in the completion of the patient screening form (SCREEN), as contained in section 400.12 of this Part."

Q4. I attended the SCREEN training course and was assigned a ten digit SCREENER identification number. Is a new Hospital/Community Patient Review Instrument (H/C PRI) number required for completing the H/C PRI?

A4. No, if you have attended H/C PRI training and have been assigned an identification number, that number remains valid for completing the H/C PRI or PRI.

Q5. I have attended SCREEN training and have not been assigned a SCREENER identification number yet. What should I do?

A5. If you have not received your SCREENER identification number within 7 weeks of taking the course, contact IPRO at 516-326-7767 ext. 325.

Q6. Can one person complete the H/C PRI and a different person complete the SCREEN?

A6. Yes, the H/C PRIand SCREEN can be completed by different persons.

• The H/C PRImust be completed by a qualified assessor who has been assigned an identification number.
• The SCREEN must be completed by a qualified SCREENER assigned a ten digit SCREENER identification number.

Q7. Can we identify the person who completed the SCREEN and verify they are a trained and qualified SCREENER?

A7. Yes, SCREEN item 38 includes the title, printed name, SCREENER identification number, and signature of the qualified SCREENER.

Screen Form

Q8. How do I obtain copies of SCREEN Form: DOH-695 (2/2009) and the Instruction Manual for SCREEN Form: DOH-695 (2/2009)?

A8. SCREEN form DOH-695 (2/2009) and Instruction Manual DOH-695i (2/2009) are available as a PDF and are found at www.nyhealth.gov/forms/#S. The form and instruction manual are also be available by calling the Department's Distribution Center at 518-465-8170 or faxing your request to 518-465-0432 (include your postal mailing address).

Updates

Q9. How will I be informed of SCREEN updates?

A9. Qualified SCREENERS should periodically check the Health Commerce System (HCS) and the NYSDOH website www.nyhealth.gov for SCREEN updates.

Q10. How do I update SCREEN Form: DOH-695 (2/2009)?

A10. The revised SCREEN Form: DOH-695 (2/2009)cannot be updated or altered. A new form must be completed when necessary.

PRI

Q11. Is there a hotline for H/C PRI and SCREEN questions?

A11. No. Answers to questions regarding the H/C/ PRI and SCREEN can be found in their accompanying instruction manuals.

• The H/C PRI manual is available at http://www.health.ny.gov/forms/#P
• The SCREEN manual is available at http://www.health.ny.gov/forms/#S
• FAQs for the SCREEN process are available at http://www.health.ny.gov/forms/#S
• H/C PRI and SCREEN questions not addressed in these documents can be emailed to hcpriscreen@health.state.ny.us
• PASRR process questions regarding mental illness should be directed to IPRO at 1-800-633-9441
• PASRR process questions regarding intellectual disability/developmental disability should be directed to OPWDD 518-473-5436
• If you are missing your H/C PRI number that was issued in 2004 or later contact IPRO at 516-326-7767 ext.325
• If you are missing your H/C PRI number that was issued prior to 2004 contact the DOH at 518-474-1057

Q12. Can the H/C PRI completion date be later than the SCREEN completion date?

A12. No, a completed H/C PRI is required to complete the SCREEN.

Q13. A completed H/C PRI is needed before I start the SCREEN. The H/C PRI was completed a while ago. Can I still use it?

A13. The H/C PRI that is used with the SCREEN must reflect the person's current condition. If the H/C PRI does not reflect the person's current condition, it cannot be used.

Screen Requirements

Q14. Why do I need to do a SCREEN?

A14. The SCREEN is required under 10 NYCRR and is based on Federal Regulations found in Title 42 Code of Federal Regulations (42 CFR), Part 483, Subpart C. The SCREEN currently serves two purposes. The first purpose of the SCREEN is to determine the person's ability to be cared for in a setting other than a Residential Health Care Facility (RHCF). The second purpose of the SCREEN is to assess persons being recommended for RHCF placement for possible mental illness and/or intellectual disability/ developmental disability, and this is accomplished with a Level I Review.

Q15. Who needs to have a SCREEN completed?

A15. A SCREEN must be completed for:

• All persons prior to admission to a RHCF.
• A hospitalized patient who is designated as Alternate Level of Care (ALC).
• Residents of a RHCF who are newly diagnosed with serious mental illness and/or intellectual disability/developmental disability.
• Residents who no longer meet the categorical determinations criteria (see items 27-30 on the SCREEN).
• Residents of a RHCF or patients designated ALC who have been previously identified as having a serious mental illness and/or intellectual disability/developmental disability and are experiencing a significant change in physical or mental condition.

Q16. What must be done for a person applying to a waiver program, and must a SCREEN be completed for a person in a waiver program?

A16. A SCREEN is required for all individuals, including those in waiver programs, who are applying for RHCF placement. Questions related to specific waiver eligibility requirements should be directed to the specific waiver program.

Q17. What are the timeframes for completing the SCREEN?

A17. The timeframes are:

• The SCREEN must be completed prior to admission to a RHCF for every person, for any reason and any length of stay.
• As soon as a person has been newly diagnosed with a mental illness and/or intellectual disability/developmental disability. (See 42 CFR 483.20(e) & 483.108(c); 42 USC 1396r (e)(7).)
• For patients designated Alternate Level of Care (ALC), the SCREEN must be completed prior to, or within 24 hours of, the patient's assignment to ALC status and every 30 days thereafter. (See 10 NYCRR Section 85.8.)
• As soon as possible when the ALC patient's status changes as evidenced by a change in the patient's assigned Resource Utilization Group (RUG-II). (See 10 NYCRR Section 85.8.)
• As soon as the person who was previously identified as having serious mental illness and/or intellectual disability/developmental disability is identified as having a significant change in physical ormental condition. A new SCREEN and Level II Evaluation must be completed within 14 calendar days. (See 42 U.S.C. Section 1396r (e)(7)(B)(iii).)
• As soon as the person no longer meets the criteria for a categorical determination on items 27-30 of the SCREEN. (See 42 CFR, Part 483, Subpart C.)

Q18. Can the date of SCREEN initiation and completion be the same?

A18. Yes, the dates may be the same.

Q19. Is a nursing home required to have a completed SCREEN before it admits the resident?

A19. Yes, 10 NYCRR 415.26 requires a SCREEN to be completed prior to admission to a RHCF. Federal Regulations 42 CFR Part 483, Subpart C require a Level I Review to be completed for all persons prior to admission to a RHCF and a Level II Evaluation to be completed for certain individuals prior to admission to a RHCF.

Q20. Our RHCF appropriately discharged a resident in accordance with all applicable federal regulations, discharge regulations set forth in 10 NYCRR Section 415.3(h), and consistent with the NYSDOH Interim Policy for Transfer/Discharge of Nursing Home Residents effective 5/1/04, and revised 12/1/04. This person would like to return to our facility. Does he need a new SCREEN completed before we can admit him?

A20. Yes, a new SCREEN form does need to be completed for this person prior to admission. He was permanently discharged from the facility and is considered a new admission.

Q21. A resident of our RHCF was transferred to the hospital and we are readmitting him. Do we need to have a new SCREEN completed prior to the resident's return?

A21. No, upon return to the RHCF, this person is considered a readmission and does not require a new SCREEN (except as noted below). This resident was not discharged from the RHCF, as the hospital is not an appropriate discharge location (refer to Q20 for regulatory citations that set forth the requirements for an appropriate discharge); rather, he was transferred to the hospital for episodic illness. Upon return to the RHCF, he is considered a readmission.

There are circumstances when a new SCREEN is required for a resident of a RHCF:

• If a RHCF resident is newly diagnosed with a mental illness and/or intellectual disability/developmental disability, a new SCREEN and Level II referral must be completed within 14 calendar days (See 42 CFR 483.20(e) & 483.108(c); 42 USC 1396r(e)(7)).
• If a RHCF resident, who was previously identified as having mental illness and/or intellectual disability/developmental disability, is identified as having experienced a significant change in physical and/or mental condition, a new SCREEN and Level II Evaluation must be completed within 14 calendar days. (See 42 U.S.C. Section 1396r (e)(7)(B)(iii)).
• If a resident of a RHCF, who was identified as having mental illness and/or intellectual disability/developmental disability on their admission SCREEN Level I Review and met the criteria for Categorical Determination (convalescent care, seriously physically ill, terminally ill, or provisional emergency admission), requires a length of stay longer than the appropriate physician documented number of days, a SCREEN and Level II Evaluation must be completed (See 42 CFR, Part 483, Subpart C).
• If a resident of a RHCF, who was identified as having mental illness and/or intellectual disability/developmental disability on their admission SCREEN Level I Review, and met the criteria for Categorical Determination for a brief or finite stay (requiring less than a 30 day stay), requires a length of stay longer than 30 days, a SCREEN and Level II Evaluation must be completed by the 40^th day. (See 42 CFR, Part 483, Subpart C.)

Q22. A resident of our RHCF was admitted to the hospital and lost his bed hold. We are readmitting him. Do we need a new SCREEN completed prior to the resident's return because he lost his bed hold?

A22. No, bed hold is a payment issue and does not qualify as a discharge. (Refer to Q20 for regulatory citations that set forth the requirements for an appropriate discharge.)

Q23. I was called to do a SCREEN on a patient going to a RHCF for rehabilitation. He will be there less than 30 days. Does he need to have a SCREEN completed?

A23. Yes, a SCREEN must be completed for all persons prior to admission to a RHCF.

Q24. Must I complete a new SCREEN before a RHCF resident is transferred to the hospital?

A24. No, a copy of the resident's most recent SCREEN, which may include a copy of a Level II Evaluation, should accompany the resident.

Q25. When did the regulations change to require a completed SCREEN prior to a sub-acute or rehabilitation stay?

A25. The regulations regarding completion of a SCREEN for persons requiring a sub-acute or rehabilitation stay in a RHCF have not changed. A completed SCREEN is required prior to any RHCF admission in accordance with 10 NYCRR 415.26 and Federal Regulations 42 CFR Part 483, Subpart C.

Q26. Must an H/C PRI and SCREEN be completed for a person entering a nursing home for hospice care?

A26. There is no regulation or policy that requires an H/C PRI and Screen be completed for an individual to obtain hospice care.

If however, the individual is entering the nursing home and will be admitted to the nursing home as a nursing home resident, an H/C PRI and Screen is required as part of the nursing home admission (regardless of whether they elect hospice care services while a resident of the nursing home). In this case, the nursing home resident may elect the hospice benefit, and the hospice can provide care to the nursing home resident (as long as there is a written contract with the nursing home) since the nursing home is considered the individual's home.

If an individual enters the (contracted) nursing home for the purposes of obtaining "Short term inpatient care" which is a required hospice service for purposes of pain control, symptom management or respite, then this individual who has elected the hospice benefit is considered a "hospice" patient. This individual is NOT being admitted to the nursing home as a nursing home resident, and no H/C PRI and Screen is required. It would be expected that this hospice patient would return to their home in the community after receiving this short term inpatient hospice care.

Identification (Items 1-6)

Q27. Item 2 requires the person's Social Security number. Can I include only the last four digits?

A27. No, the full number is required.

Direct Referral Factor for RHCF (Item 7)

Q28. This person has a home in the community (owns or rents a home, lives in an Adult Care Facility or with family or friends) and that residence is still available, but the person is not capable of living alone in that home or the home is unsafe. Do I answer YES to item 7?

A28. You must explore all appropriate community based options as to what physical living space is available. Item 7 addresses physical living space only. Safety factors will be addressed in other items.

Q29. Could a shelter be considered an appropriate community based option?

A29. If a shelter meets a particular person's needs, it may be considered as an appropriate community based option. Some shelters provide more services than others, although most are intended for temporary placement.

Q30. Our goal for this person is RHCF placement. Should I answer NO to item 7?

A30. All information on the SCREEN must accurately reflect the person's current condition and circumstances. Answer the item as it relatestothis person's current condition.

DIRECT REFERRAL FACTORS FOR COMMUNITY BASED ASSESSMENT (Items 8-12)

Q31. Must a community based assessment be completed as a part of every SCREEN?

A31. No, if all Direct Referral Factors For Community Based Assessment (items 8-12) are marked NO, do not refer for a community based assessment.

Q32. When must a community based assessment be completed as a part of a SCREEN?

A32. If any Direct Referral Factors For Community Based Assessment (item 8-12) is answered YES, a community based assessment must be completed.

Q33. Who can complete a community based assessment?

A33. A community based assessment can be completed by qualified, competent individuals or authorized agencies including, but not limited to:

• Certified Home Health Agencies (CHHA), including VNA and Public Health
• Lombardi Long Term Home Health Care Programs (LTHHCP)
• Community Alternative Systems Agencies (CASA)
• Health Homes and Managed Long Term Care programs

Q34. Must the community based assessment be completed by a qualified SCREENER?

A34. No, refer to A33.

Q35. Who is considered an informal support (item 10)?

A35. An informal support is defined as an individual who provides any service to this person on a voluntary (unpaid) basis. Informal supports may include service providers that charge no fee or a nominal fee (i.e., friendly visiting). Refer to the Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 10.

Q36. Item 12 refers to the person's ADL status prior to the most recent acute episode. How do I find out what his/her ADL status was?

A36. Sources of data for completing the SCREEN may include the person, informal supports (family, friends, and neighbors), formal service agencies, medical records and professional staff.

Q37. Must I always interview family members and informal supports?

A37. No, although they may be a valuable resource for important information regarding the person being assessed. (See A35)

Q38. If any of the Direct Referral Factors For Community Based Assessment (items 8, 9, 10, 11, or 12) is answered YES and the person is referred for a community based assessment, do I (the qualified SCREENER) need to continue completing the SCREEN?

A38. Yes, you need to continue completing the SCREEN based on the outcome of the community based assessment. If the community based assessment determines that the person can or cannot be cared for in the community, the SCREENER attaches the community based assessment to the SCREEN and proceeds to Referral Recommendation, and continues as the guidelines direct.

Home and Caregiving Arrangements (Items 13-20)

Q39. The informal support system is not available on certain days of the week (item 13). When I estimate the number of hours per day that the informal support is able to assist, as the Instruction Manual directs, it does not reflect a true picture of the person's circumstances. How do I document this?

A39. The SCREENER is providing an estimate of hours based on the available information. The criteria can be found in the Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 13. If there are days when no one is available, you may attach additional supporting documentation and document that information on the SCREEN.

Q40. Item 14 references the person's potential situation within six months. What do I base my answer on?

A40. Your answer should be based on interviews, record review, observation and your professional judgment.

Referral Recommendation (Item 21)

Q41. Item 21 has six referral recommendation options. How do I determine which one to choose?

A41. Your referral recommendation is based upon your answers to items 7-20 on the SCREEN.

Dementia Diagnosis (Item 22)

Q42. If the person has a diagnosis of dementia documented in the medical record (item 22) do I need to continue completing the SCREEN?

A42. Yes, follow the guidelines and proceed to item 23.

Q43. What if the family says the person has dementia?

A43. A family reported finding does not qualify as a documented diagnosis. Answer item 22, YES, only if the person has a diagnosis of dementia (including Alzheimer's disease) documented by a medical practitioner in the medical record.

Level I Review for Possible MI (Item 23)

Q44. Why do I need to do a Level I Review?

A44. Federal Regulation 42 CFR Part 483, Subpart C requires a Level I Review (items 23-26) for possible mental illness and/or intellectual disability/developmental disability for all persons prior to admission to a RHCF.

Q45. When must a Level I Review be completed?

A45. A Level I, Pre-Admission Screen Resident Review (PASRR) (items 23-32) must be completed when a person's SCREEN Referral Recommendation (item 21) indicates RHCF (a) (1, 2, 3 or 4) or RHCF for Restorative Services (b) (1).

Q46. What is the timeframe for completing a Level I Review?

A46. A Level I Review must be completed concurrent with completion of the SCREEN. See A17 for specific timeframes.

Q47. Where do I find guidance to help me answer item 23 correctly?

A47. Refer to the Instruction Manual for SCREEN Form: DOH-695 (2/2009) item 23, to determine if this person is considered to have a serious mental illness for Level I Review purposes. The SCREENER must carefully review all of the requirements for this item to determine if the individual meets all of the criteria on diagnosis, level of impairment and duration of illness/recent treatment.

Q48. If a person has a diagnosis of dementia and no major mental disorders diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM) and meets all the other criteria for level of impairment, recent treatment, and duration of illness is he considered to have a serious mental illness for PASRR purposes?

A48. No, although dementia is listed in the DSM it is considered a cognitive disorder.

Q49. Should the person described above be referred for a Level II?

A49. No, this person does not meet the PASRR definition of having a serious mental illness.

Q50. If a person has a diagnosis of dementia and another major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders (DSM) and he meets all the other criteria for level of impairment, recent treatment, and duration of illness, should he be referred for a Level II?

A50. Yes, IPRO will review the available information and may determine that the dementia is primary. Also see A51.

Q51. Our resident was identified on a SCREEN as having a serious mental illness and a referral was made for a Level II PASRR. The NYS Level II Adult Mental Health Evaluation Report stated, "Please note that future PASRR Level II Mental Health Evaluations are not required for this person, unless the person ceases to have a primary diagnosis of dementia/Alzheimer's or is determined to be able to benefit from mental health services." This resident has been identified as having a significant change in condition on the MDS. Must a referral be made for a new Level II PASRR?

A51. No, a significant change in condition does not require this resident to be referred for a Level II PASRR. If the resident ceases to have a primary diagnosis of dementia or is determined by the interdisciplinary team to be able to benefit from mental health services a referral for Level II PASRR would be made.

Q52. If a person has a diagnosis such as psychotic disorder and the psychotic disorder is due to a medical condition, and the person meets all the other criteria for a serious mental illness for PASRR purposes, should a referral be made for a PASRR Level II?

A52. Yes, a referral for a PASRR Level II should be made.

Q53. Are individuals with a Traumatic Brain Injury (TBI) subject to PASRR?

A53. All individuals applying to a Medicaid-certified NF must undergo at minimum a Level I evaluation, whether they have TBI, some other mental disability, or no mental disability. Whether an individual with TBI should test positive at Level I depends upon when the TBI was acquired. If it was acquired before the age of 22, results in significant intellectual impairment and functioning, and is likely to continue indefinitely, then the individual should test positive at Level II/MR because they would be classified as having a related condition (RC).

If an individual acquired TBI after the age of 22, they should not test positive at Level I/MR. However, it is entirely possible that the TBI has produced or aggravated a serious mental illness that would cause the individual to test positive at Level I/MI. But in that case, the TBI is largely secondary to the MI. A person-centered plan of care would account both for the TBI and for the MI, but, for PASRR purposes, only the MI would be relevant.

Q54. If a person meets all the criteria for serious mental illness but has not had a psychiatric hospitalization in the last two years, could he still meet the definition of serious mental illness for PASRR purposes?

A54. Yes, if within last two years, due to the mental disorder, the patient's treatment history includes a significant disruption to the normal living situation that required supportive services to maintain functioning at home or in a residential treatment environment, or resulted in intervention by housing or law enforcement officials, he meets the definition for having a serious mental illness for PASRR purposes.

Q55. Our resident had a PASRR NYS Level II Adult Mental Health Evaluation completed prior to admission. At that time he met the definition for serious mental illness. He has been psychiatrically stable and recently had a significant change in condition. When I complete the SCREEN he no longer meets the definition for serious mental illness. How do I answer item 23?

A55. Item 23 should be answered YES, if the resident met the definition for serious mental illness at the time of admission. The PASRR contractor (IPRO) may make the determination that the resident does not meet the definition of serious mental illness for PASRR purposes and issue these findings in the PASRR NYS Level II Adult Mental Health Evaluation Report.

Q56. Our resident had a PASRR NYS Level II Adult Mental Health Evaluation and the report determined that the resident does not meet the definition for serious mental illness for PASRR purposes. This resident meets the MDS definition for a significant change in condition. Must I refer this resident for a Level II?

A56. No, unless the resident's change in condition is such that he now meets all the criteria for a serious mental illness.

LEVEL I REVIEW FOR POSSIBLE MR/DD (Items 24-26)

Q57. Are the Developmental Disabilities Regional Offices (DDRO), which operate under the authority of the Office for People with Developmental Disabilities (OPWDD), responsible to conduct Level II Evaluations for individuals who are not known to the OPWDD system?

A57. Yes. In accordance with PASRR, all persons who seek admission to an RHCF are screened to determine whether they appear to present with a mental disability, including intellectual disability or developmental disabilities. If they appear to have such a disability, the person must be referred to the appropriate DDRO for a PASRR Level II Evaluation. The DDRO must initiate a Level II Evaluation whether or not the person is known to the OPWDD system of care. The Level II Evaluation includes verification of intellectual disability or other developmental disability, as well as a review of whether the person is appropriate for the level of care provided by the RHCF, and whether the person is in need of specialized services or services of a lesser intensity.

If the DDRO cannot determine that the person meets the criteria for intellectual disability or developmental disability, the Level II Evaluation is terminated. The person is informed of additional steps that may be taken to establish the disability. The process for admitting the person to the nursing facility may proceed without completion of the entire PASRR Level II Evaluation. If the person is admitted to the nursing facility and is later determined by OPWDD to have intellectual disability or another developmental disability, a new Level II Evaluation may be initiated.

Categorical Determination (Items 27-30)

Q58. What exactly is convalescent care?

A58. For the purposes of completing the SCREEN, convalescent care is defined as a medically prescribed period of post-acute hospitalization recovery in a RHCF not to exceed 120 days as documented by the physician in the medical record. The criteria can be found in the Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 27.

Q59. Would the administration of IV antibiotics in a RHCF qualify as convalescent care?

A59. A physician's order for IV antibiotics alone would not meet the qualifying criteria for convalescent care as a Categorical Determination (see Instruction Manual for item 27).

Q60. Isn't any person in the hospital considered seriously physically ill?

A60. No, not every person in the hospital meets the SCREEN criteria for seriously physically ill. The criteria can be found in the Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 28.

Q61. If the H/C PRI documented the person was terminally ill, should I answer item 29 YES?

A61. No, for the purposes of completing the SCREEN, the definition of terminally ill is a person for whom there is documentation in the medical record, by the physician, that his/her life expectancy is six months or less. The criteria can be found in the Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 29.

Q62. I think this person will only have a brief stay in the RHCF. I do not have documentation supporting this. Can I answer item 30 YES?

A62. No, before admission to the facility, documentation is required including certification by the attending physician that the individual is likely to require less than 30 days nursing facility services. (See 42 CFR, Subpart C 483.106)

Danger to Self or Others Qualifiers (Items 31-32)

Q63. Review of the person's medical records raises a question about whether the person is a danger to self or others. How do I answer item 31?

A63. If there is any question about whether the person is a danger to self or others answer the item YES and seek a psychiatric evaluation as noted in the Instruction Manual for SCREEN Form: DOH-695 (2/2009).

Q64. If a person is forgetful or noncompliant with medications or treatments, would this be considered a danger to self or others (item 31)?

A64. If the person's behavior raises any questions about whether he/she is a danger to self or others, answer item 31 YES. Refer to the Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 31, for details.

Q65. Item 32 requires a psychiatric evaluation before I can continue the SCREEN process. The person is refusing the psychiatric evaluation. What should I do?

A65. This should be addressed on an individual basis by the medical team.

Q66. Item 32 references a licensed mental health professional. Who can complete the psychiatric evaluation referenced in item 32?

A66. The evaluation must be consistent with NYS licensure and scope of practice guidelines. The Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 32 notes that the psychiatric evaluation must be completed by one of the following: a board certified/eligible psychiatrist, Ph.D. psychologist, psychiatric nurse or MSW social worker.

Level II Referrals (Items 33-34)

Q67. Why do I need to make a Level II Referral?

A67. The Level I Review will identify persons suspected or known to be affected by serious mental illness and/or intellectual disability/developmental disability. Federal Regulation 42 CFR Part 483, Subpart C requires a Level II Referral for those persons to determine whether RHCF placement is appropriate or if specialized services are required.

Q68. Under what circumstances must a Level II Referral be made?

A68. A Level II Referral must be made when:

• The Level I Review determines the person to have possible serious mental illness (item 23 is marked YES) and/or possible intellectual disability/developmental disability (item 24, 25 or 26 is marked YES) and the person does not meet any of the Categorical Determinations (items 27-30 are marked NO).
• The person has been determined to meet a Categorical Determination (any item 27-30 is marked YES) but is determined to be a danger to self or others based on a current psychiatric evaluation by a licensed mental health professional (item 32 is marked YES).
• The person no longer meets the criteria for a Categorical Determination.
• The person was previously identified as having serious mental illness and/or intellectual disability/developmental disability and is identified as having a significant change in physical or mental condition.
• The person is newly diagnosed with a serious mental illness and/or intellectual disability/developmental disability.

Q69. How do I make a Level II Referral?

A69. Refer to the Instruction Manual for SCREEN Form: DOH-695 (2/2009), item 33, for details.

Q70. Can the person be placed in a RHCF while we wait for the Level II Recommendation?

A70. No, the purpose of the Level II Evaluation is to determine if a RHCF would be an appropriate placement and can meet the needs of the person.

Q71. We admitted a resident who met the criteria for convalescent care (item 27 is answered YES). It now appears the person will reside at the facility longer than 120 days. What should I do?

A71. As soon as it has been determined that the person will reside in the facility longer than 120 days, a new SCREEN must be completed. The person no longer meets the criteria for a Categorical Determination, and must have a LEVEL II Referral made. Follow the guidelines on the SCREEN and the Instruction Manual for SCREEN Form: DOH-695 (2/2009).

Q72. We admitted a resident whose physician certified that the person would reside at the facility for less than 30 days (item 30 is answered YES). It now appears the person will reside at the facility longer than 30 days. What should I do?

A72. As soon as it has been determined that the person will reside in the facility longer than the physician certified length of stay, a new SCREEN must be completed. The person no longer meets the criteria for a brief and finite stay, and must have a Level II Referral made. The Level II Evaluation must be conducted within 40 calendar days of admission. (See 42 CFR, Subpart C 483.106 (b)(2)(ii).) Follow the guidelines on the SCREEN and the Instruction Manual for SCREEN Form: DOH-695 (2/2009).

Q73. The Level I Review identified the person as having possible mental illness and possible intellectual disability/developmental disability. Should I simultaneously refer the person for a Level II Mental Illness Evaluation and for a Level II Intellectual Disability/Developmental Disability Evaluation?

A73.You must determine which referral to make first. Follow the guidelines in the SCREEN and the Instruction Manual for SCREEN Form: DOH-695 (2/2009).

Q74. For a RHCF resident, how do I determine if a significant change has occurred for the person identified on the Level I Review as having a serious mental illness and/or intellectual disability/developmental disability?

A74. Guidelines for determining a significant change can be found in Chapter 2 of the current MDS 3.0 User's Manual.

Q75. Can item 34 be answered NO?

A75. If the patient/resident/person is being referred for a Level II evaluation item 34 must be answered YES. Once completed the Notification of Need for Level II Evaluation (page 7) will serve as the written notification. The SCREENER must also provide verbal notification.

Level II Recommendations (Item 35)

Q76. What is the timeframe for completing a Level II PASRR?

A76. Federal Regulation 42 CFR 483 Subpart C requires a Level II PASRR to be completed 7-9 business days after request, on average.

Q77. We referred a person for a Level II Evaluation nine days ago and still do not have the results. Who do I contact?

A77. Contact the mental health and/or intellectual disability/developmental disability review entity that is handling the Level II referral.

Q78. If the Level II Evaluation for a person with mental illness recommends the need for specialized services, can the person be placed in a RHCF?

A78.An RHCF does not provide specialized services for persons with serious mental illness; therefore, an RHCF would not meet the needs of persons with serious mental illness. The Medicaid State Plan and Federal Regulation 42 CFR 483 Subpart E provide an appeals process for the person. The person being evaluated has a right to appeal the decision through a fair hearing process by an Administrative Law Judge.

Q79. Our interdisciplinary team has determined that the resident's needs have changed and the Services of Lesser Intensity recommended on the resident's most recent PASRR NYS Level II Adult Mental Health Evaluation Report no longer meet his needs. Can we revise the Services of Lesser Intensity we provide?

A79. The Services of Lesser Intensity Recommendations listed on the report should be incorporated into the resident's interdisciplinary plan of care. As the resident's needs change, the plan of care should be revised to meet the resident's needs and goals. Documentation in the medical record should support the change to the plan of care. If the resident has had a significant change in condition (see A74) a referral should be made for a Resident Review.

Q80. If the Level II Evaluation recommends a "community setting" can the nursing home admit this person?

A80. No, the person may not be admitted to the nursing home.

Q81. A resident in our RHCF was transferred to the hospital. He had been previously identified as requiring a PASRR. We have identified that he has experienced a significant change in condition and requested a Resident Review PASRR be completed before he returns to our RHCF. The Resident Review PASRR recommended placement option is, "The individual's total needs are such that his or her needs can be met in the appropriate community setting." Should this resident return to our RHCF?

A81. Yes, the resident should return to the RHCF for discharge planning to the most integrated, appropriate, community housing with appropriate services. The hospital is not an appropriate discharge outlet. The RHCF should document its discharge planning efforts in the resident's record and include documentation to support that the resident was actively involved in the decision making process and planning.

Q82. The above mentioned resident lost his bed hold and our facility has no open beds. Can the hospital transfer our resident to another RHCF?

A82. Yes, the facility that accepts this resident will begin discharge planning. Your facility must offer the resident the opportunity to return to the next available bed (10NYCRR 415.3). If the resident is transferred back to your RHCF before discharge to the community, your RHCF must continue the discharge planning process.

Q83. The above mentioned resident has returned to our RHCF, and he does not want to be discharged to the community. What can he do?

A83. The resident can appeal the PASRR determination. Page 4 of the PASRR NYS Level II Adult Mental Health Evaluation Report (DOH- 5027 10/2011) contains instructions for obtaining a hearing with the New York State Office of Temporary and Disability Assistance (OTDA).

Q84. The PASRR NYS Level II Adult Mental Health Evaluation Report is recommending services of lesser intensity including recovery oriented clinical counseling focused on goal achievement by overcoming barriers due to the individual's mental illness. Who can provide this clinical counseling?

A84. A Licensed Clinical Social Worker (LCSW) can provide clinical counseling. A BSW or MSW can also provide clinical counseling if supervised by a LCSW, psychiatrist, or psychologist.

Q85. The PASRR NYS Level II Adult Mental Health Evaluation Report is recommending services of lesser intensity including therapeutic group interventions that will assist in addressing the emotional, cognitive and behavioral symptoms of a mental health disorder. Who can provide the therapeutic group interventions?

A85. The recommendation for therapeutic group interventions must be incorporated into the resident's interdisciplinary care plan. The recommended interventions should be tailored to address the resident's emotional, cognitive and behavioral symptoms. The staff member providing care planned interventions should be supervised by a LMSW.

Patient/Resident/Person Disposition (Item 36)

No questions were submitted.

Patient/Resident/Person and/or Legal Representative and/or Health Care Agent Acknowledgement (Item 37)

Q86. Item 37 requires a signature, but the person is not capable of signing. What do I do?

A86. The acknowledgement cannot be left blank if this person is unwilling/unable to sign, and this person has no legal representative or health care agent. If the person is unwilling or unable to sign item 37, the SCREENER must enter the reason in the space where the signature is required and have a witness cosign the reason with the SCREENER. The person being SCREENED should have the opportunity to sign the documents, if at all possible, since they are part of the SCREEN process. See the Instruction Manual for SCREEN Form: DOH-695 (2/2009) for details.

Qualified Screener (Item 38)

No questions were submitted.

Notification of Need for Level II Evaluation (Page 7)

Q87. Why do I need to give the person being referred for a Level II Evaluation a copy of page 7 of the SCREEN?

A87. Federal Regulation 42 CFR Subpart C 483.128(a) "…requires the issuance of written notice to the individual or resident, and his or her legal representative, that the individual or resident is suspected of having MI (mental illness) or MR (intellectual disability/developmental disability) and is being referred to the State mental health or mental retardation authority for Level II screening."

Requirements for RHCF Admission from Out-Of-State

Q88. A person residing out-of-state is seeking admission to our RHCF. Is an H/C PRI and SCREEN required prior to admission?

A88. Yes, prior to admission to a NYS RHCF a Hospital/Community Patient Review Instrument (H/C PRI) (DOH-694 12/05) and SCREEN form (DOH-695 2/2009) must be completed by a trained and qualified H/CPRI Assessor and/or Screener respectively.

Q89.Can an out-of state health care professional complete the H/C PRI and SCREEN?

A89. Yes, out-of-state health care professionals may complete the H/C PRI and/or SCREEN if they are trained and qualified H/C PRI Assessors and/or Screeners and have been assigned an H/C PRI Assessor number and a 10 digit SCREENER identification number.

Q90. The out-of-state provider does not have staff trained and qualified to complete the H/C PRI and SCREEN. What should they do?

A90. If the out-of-state provider does not have staff trained and qualified to complete the H/C PRI and/or SCREEN, the provider may work with an agency or health care professional who is trained and qualified. Such agencies may include NYS certified home health agencies (CHHA), home health agencies, or visiting nurse associations.

Q91. A person seeking placement in a NYS RHCF is residing in Florida. How can an assessment be completed?

A91. It is the Department's expectation that the H/C PRI and SCREEN assessments will be conducted face-to-face. The Department recognizes that there are rare occasions when a face-to-face assessment is not possible. The trained and qualified H/CPRI Assessor and Screener should work with the person and the out-of-state health care provider to obtain the information required for completing the forms. The assessor/ SCREENER should interview the person and/or his or her legal representative/health care agent and health care provider via telephone and review documentation as required. The SCREENER should work with the out-of-state health care provider to obtain the person's signature on item 37. On SCREEN item 38 the Screener should document the reason the SCREEN cannot be completed face-to-face and provide details on how the form was completed. If required the SCREENER should complete page 7 of the SCREEN form and work with the out-of-state health care provider to provide the person being referred for a Level II Evaluation the required notification. On item 35 of the H/C PRI the Assessor should document the reason the assessment could not be completed face-to-face and provide details on how the assessment was completed.

Q92. Can our RHCF complete the H/C PRI and SCREEN after we admit the person from out-of-state?

A92. No, the H/C PRI and SCREEN, and if required a Level II Evaluation, must be completed prior to admission to ensure the appropriateness of admission, care and services.