N.J. Admin. Code § 10:52-1.11

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:52-1.11 - Preadmission screening for nursing facility (NF) placement

(a) The Department of Health and Senior Services is the agency responsible for administering the Preadmission Screening Program. The following is provided to hospitals so that they understand the process and the rules a hospital shall follow to ensure Medicaid or NJ FamilyCare-Plan A reimbursement for the care of individuals whose discharge planning includes placement into a nursing facility.

(b) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise.

"Health Services Delivery Plan (HSDP)" means an initial plan of care prepared during the Preadmission Screening (PAS) process. The HSDP reflects the individual's current or potential problems, required care needs, the need for Preadmission Screening and Resident Review (PASRR) and the Track of Care.

"Level I PASRR screen" means the process of identification of an individual meeting the criteria for serious mental illness (MI) or mental retardation (MR) or both, as described throughout this section, and determining whether the individual also meets the NF level of care requirements.

"Level II PASRR evaluation" means the process of evaluating and determining whether an individual meets NF level of care, and determining whether an individual needs specialized services for MI or MR or both. An individual who requires specialized services cannot receive those services in a NF.

"Preadmission screening (PAS)" means that process by which all Medicaid eligible beneficiaries seeking admission to a Medicaid certified NF and individuals who may become Medicaid eligible within six months following admission to a Medicaid certified NF, receive a comprehensive needs assessment by professional staff designated by the Department of Health and Senior Services to determine their long-term care needs and the most appropriate setting for those needs to be met, pursuant to 30:4D-17.1 0. ( P.L. 1988, c.97.)

"Preadmission Screening and Resident Review (PASRR)" means that process by which all individuals meeting the clinical criteria for mental illness (MI) or mental retardation (MR), regardless of payment source, are screened prior to admission to an NF in order to determine the individual's appropriateness for NF services, and whether the individual requires specialized services for his or her condition. PASRR includes two levels, Level I PASRR screen and Level II PASRR evaluation, as defined above and described in this section.

"Professional staff designated by the Department of Health and Senior Services (DHSS professional staff)" means a nurse licensed or certified in accordance with N.J.A.C. 13:37 or a social worker who performs health needs assessments and care management counseling in accordance with this section.

"Specialized Services for Mental Illness (MI)" means those services that are determined to be medically indicated when an individual is experiencing an acute episode of serious mental illness and psychiatric hospitalization is recommended, based upon a Psychiatric Evaluation. Specialized Services entail implementation of a continuous, aggressive and individualized treatment plan by an interdisciplinary team of qualified and trained mental health personnel. During a period of 24-hour supervision of the individual, specific therapies and activities are prescribed, with the following objectives: to diagnose and reduce behavioral symptoms; to improve independent functioning; and as early as possible, to permit functioning at a level where less than Specialized Services are appropriate. Specialized Services go beyond the range of services that an NF is authorized to provide and can only be provided in a 24-hour inpatient psychiatric setting.

"Specialized Services for Mental Retardation (MR)" means those services required when an individual is determined to have skill deficits or other specialized training needs that necessitate the availability of trained MR personnel, 24-hours per day, to teach the individual functional skills. Specialized Services are those services needed to address such skill deficits or specialized training needs. Specialized services may be provided in an Intermediate Care Facility for the Mentally Retarded (ICF/MR) or in a community-based setting which meets ICF/MR standards. Specialized services go beyond the range of services which a NF is authorized to provide.

"Track of care" means designation of the setting and scope of Medicaid/NJ FamilyCare-Plan A services as determined by the PAS process. The PAS is conducted by the professional staff designated by the Department of Health and Senior Services (DHSS) following an assessment of the Medicaid or NJ FamilyCare-Plan A beneficiary or potential Medicaid or NJ FamilyCare-Plan A beneficiary, as follows:

1. "Track I" means long-term NF care;

2. "Track II" means short-term NF care; and

3. "Track III" means long-term care services in a community setting.

(c) Preadmission screening (PAS) authorization shall be required prior to admission to a Medicaid certified NF of a Medicaid or NJ FamilyCare-Plan A beneficiary, or an individual who may become a Medicaid or NJ FamilyCare-Plan A beneficiary within six months following placement in a Medicaid certified NF. If the NF applicant has received psychiatric inpatient care for a year or more, a PASRR shall be performed, in addition to the PAS, prior to admission. Professional staff designated by DHSS shall assess each individual's care needs and determine the appropriate setting for the delivery of needed services. Professional staff designated by DHSS will authorize or deny NF placement based on the clinical eligibility requirements at 8:85-2.1 and the feasibility of alternative placement and will designate the track of care, in accordance with 8:85-1.8.

(d) PAS authorization is also required for individuals identified as having a serious MI or MR regardless of the payment source. The PASRR assessment and authorization process shall be subsumed within the State's PAS protocols, as required by (e) below.

1. A Level I PASRR screen shall be required for individuals suspected of, or diagnosed as having serious MI, MR, or both or related conditions.

2. An individual is considered to have a serious mental illness (MI) if he or she has a mental illness, such as schizophrenia, mood disorder, paranoia, panic or severe anxiety disorder, or similar condition found in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR 2000 edition) (available from the American Psychiatric Association, 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22269-3901 and www.psych.org) that leads to a chronic disability and that meets the PASRR requirements for diagnosis, level of impairment and duration of illness.

i. An individual is considered to have dementia if he or she has a primary diagnosis of dementia, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR 2000 edition) and does not have a serious mental illness.

3. An individual is considered to have mental retardation (MR) if he or she has a level of retardation (mild, moderate, severe or profound) described in the "American Association on Mental Retardation's Manual on Classification in Mental Retardation (1983)" or a related condition, as defined by, and pursuant to, Section 1905(d) of the Social Security Act (Omnibus Budget Reconciliation Act of 1987 P.L. 100-203); 42 U.S.C. § 1396(d), and (d)3i below. An individual with a diagnosis of MR or a related condition and a diagnosis of dementia shall receive a Level II PASRR screen prior to admission to a Medicaid certified nursing facility.

i. "Persons with related conditions" means individuals who have a severe and chronic disability that meets all of the following conditions:

(1) The person has a diagnosis of mental retardation (MR) or other developmental disability, such as cerebral palsy, epilepsy, autism, spina bifida or other neurological impairment; and

(2) The person has a history or past records which show that the onset of the mental retardation or related conditions occurred prior to age 22.

4. A Level II PASRR evaluation shall be conducted for mentally ill or mentally retarded individuals only if the assessment performed by the professional staff designated by DHSS results in authorization of NF placement.

i. A Level II PASRR evaluation for individuals with serious MI requires that a psychiatric examination be performed by a Board eligible/certified psychiatrist or APN certified in mental health to determine the need for specialized services, in accordance with (e) below. When all reasonable efforts to secure a psychiatrist fail, an M.D. or D.O. who is not a psychiatrist may perform the examination.

ii. A Level II PASRR evaluation for MR individuals will be performed by the Division of Developmental Disabilities (DDD) to determine the need for specialized services, in accordance with (e) below.

5. Hospitals shall not transfer an individual requiring a Level II PASRR evaluation to Medicaid-certified NFs until the Level II PASRR has been conducted and the hospital has received a Department of Health and Senior Services Office of Community Choice Options letter of approval indicating that the individual does not require specialized services.

6. For individuals diagnosed with Alzheimer's or related dementias, documentation to support the diagnosis, including the history, physical examination and diagnostic workup shall be provided to the admitting Medicaid certified nursing facility for the individual's clinical record.

7. After an initial PASRR process has been completed, the individual transferred from a nursing facility to an acute care general hospital or an individual with serious MI being transferred to a psychiatric hospital for less than one year shall not require a Level I PASRR screen or a Level II PASRR evaluation prior to transfer back to a nursing facility. If the individual is transferred to a different facility, the hospital discharge planner shall advise the admitting NF of the individual's former NF placement.

(e) The determination of the necessity for NF level of care shall be performed through Preadmission Screening (PAS), as mandated by 30:4D-17.1 0. Professional staff designated by DHSS shall determine the necessity for NF level of care for Medicaid and NJ FamilyCare-Plan A beneficiaries, for individuals who may become Medicaid and NJ FamilyCare-Plan A beneficiaries within six months following admission to a Medicaid certified facility, and for individuals identified as meeting PASRR Level I criteria. The Office of Community Choice Options (OCCO) having jurisdiction for the area where an acute care hospital is located has the responsibility for completing the PAS assessment regardless of the beneficiary's county of residence or anticipated county of discharge. A listing of the Offices of Community Choice Options can be obtained by writing to the Director, Division of Aging and Community Choice Options, Department of Health and Senior Services, PO Box 807, Trenton, New Jersey 08625-0807, or by accessing the DHSS Division of Consumer Support website at www.state.nj.us/health/consumer/directory.htm, or by accessing the fiscal agent website at www.njmmis.com and clicking on the "Frequently Asked Questions" tab.

1. Professional staff designated by DHSS will review the medical, nursing and social information obtained at the time of assessment, as well as any other supporting data, in order to assess the individual's care needs and determine the appropriate setting for the delivery of needed services. The professional staff designated by DHSS will authorize or deny NF placement based on the clinical eligibility requirements found at 8:85-2.1 and the feasibility of alternative placement. Professional staff designated by DHSS will also designate the track of care.

i. If alternative care is available, accessible and appropriate to the needs of the individual, the request for NF placement will be denied.

ii. If an appropriate alternative placement becomes available and accessible for a person already approved for NF care and awaiting placement, the authorization for NF placement will be rescinded.

iii. The professional staff designated by DHSS will advise the hospital discharge planner or social worker of the NF level of care approval and the setting for the delivery of needed services. If the individual requires a Level II PASRR evaluation, a letter will be given to the individual advising him or her that the Level II PASRR evaluation must be completed prior to admission to the NF.

2. The professional staff designated by DHSS will schedule and perform the assessment process within three working days of the hospital discharge planner or social worker's initial contact with the OCCO. Individuals who exhibit unstable, severe medical conditions, such as a patient in the Intensive Care or Coronary Care Unit or a patient who is awaiting surgery, shall not be referred for PAS until that condition has stabilized.

3. A signed Release of Information form shall be obtained from the potentially Medicaid-eligible patient. If the patient refuses NF placement, home care services, or participation in the PAS assessment process, the professional staff designated by DHSS will make every effort to obtain a signed participation declination statement, which will be included in the patient's OCCO case record.

4. NF placement approval: The professional staff designated by DHSS will verbally advise the hospital discharge planner or social worker and patient or legal representative of the assessment decision.

i. For a Track I or II determination, the professional staff designated by DHSS will leave a copy of the HSDP and signed approval letter with the discharge planner or social worker. For individuals requiring a Level II PASRR evaluation, the signed approval letter and HSDP shall be forwarded only after the determination has been made that no specialized services are required.

ii. For a Track III determination, the professional staff designated by DHSS will leave a copy of the HSDP with the discharge planner or social worker to forward to the home care provider. The discharge planner or social worker shall arrange needed home health services and forward a copy of the HSDP to the home care agency. A Track III determination shall not be an authorization for NF services.

iii. The original approval letter signed by the professional staff designated by DHSS will be sent by the OCCO to the individual or his or her legal representative with copies to the county welfare agency (CWA).

iv. A copy of the HSDP must be attached to the hospital discharge material and forwarded with the patient to the admitting NF.

(1) If the patient being transferred will be eligible for Medicare benefits, the transfer shall be made to a Medicare/Medicaid participating NF.

5. NF placement denial: The professional staff designated by DHSS will verbally advise the hospital discharge planner or social worker and patient or the patient's legal representative of the assessment decision. The professional staff designated by DHSS will leave a signed copy of the NF placement denial letter with the discharge planner or social worker. The original denial letter, signed by the professional staff designated by DHSS, will be sent to the patient or the patient's legal representative by the OCCO, with copies to the county welfare agency (CWA).

(f) The hospital discharge planner or social work staff shall be responsible for identifying a Medicaid or NJ FamilyCare-Plan A beneficiary inpatient or a Medicaid or NJ FamilyCare-Plan A applicant inpatient who may be at risk of NF placement.

1. The identification process shall also include any inpatient in need of NF care who may become a Medicaid or NJ FamilyCare-Plan A beneficiary within six months after NF admission, as well as individuals meeting PASRR Level I criteria. (See 10:52-1.9(c).) These patients shall be referred by the hospital to the OCCO and the CWA on the basis of the "At Risk Criteria for Nursing Facility Placement and Referral to the OCCO for PAS Evaluation" in (g) below. Medicaid or NJ FamilyCare-Plan A beneficiaries already residing in Medicaid participating facilities who are transferred to an acute care hospital and who are transferred to either the same or a different NF, shall not require PAS authorization.

i. Within one working day of identifying an inpatient as being at risk for NF placement, the hospital discharge planner or social worker shall:

(1) Make a telephone or FAX referral to the OCCO and the CWA;

(2) If not already a Medicaid or NJ FamilyCare-Plan A beneficiary, generate a Public Assistance Inquiry (PA-1C) to initiate the application process for Medicaid or NJ FamilyCare-Plan A; and

(3) Within two working days of the telephone referral to the OCCO and CWA, the Hospital Discharge Planning Office shall forward the completed "Hospital Preadmission Screening Referral (LTC-4)" to the OCCO, unless the LTC-4 was faxed on the day of the referral.

2. The Level II PASRR evaluation for individuals identified as meeting the PASRR criteria shall be completed by a Board eligible or Board certified psychiatrist or APN certified in psychiatric/mental health:

i. The hospital discharge planning unit or social services department shall immediately arrange through the individual's attending physician, a consultation by a Board eligible, a Board certified hospital staff psychiatrist or an APN certified in mental health to complete the "PASRR Psychiatric Evaluation" (DMHS 2009) form. The "PASRR Psychiatric Evaluation" form shall not be completed until such time as the professional staff designated by DHSS has determined the level of care and the need for a PASRR Level II evaluation.

ii. Within 48 hours of completion of the PASRR Level II evaluation, the completed "PASRR Psychiatric Evaluation" form shall be faxed to (609) 777-0662 or mailed to the Division of Mental Health Services, PO Box 727, Trenton, New Jersey 08625-0727, Attention: PASRR Coordinator.

(1) A copy of the "PASRR Psychiatric Evaluation" form may be requested from the PASRR Coordinator in the Division of Mental Health Services.

iii. The OCCO shall contact the appropriate Regional Office of the Division of Developmental Disabilities (DDD) agency to advise them of the need for a Level II PASRR evaluation. The Level II PASRR evaluation will be completed by the DDD staff within three working days of the OCCO contact.

iv. DMHS or DDD shall notify the OCCO of the determination of need for specialized services who, in turn, shall provide the hospital discharge planning unit or social services department with the approval or denial decision for placement in a Medicaid-certified NF.

(g) The following "At-Risk Criteria for Nursing Facility Placement and Referral to the OCCO for PAS" shall be utilized by the hospital in determining if a referral for long-term care services, either in an NF or in the community, is indicated:

1. The medical criteria are as follows. Has the patient experienced any of the following:

i. Catastrophic illness requiring major changes in lifestyle or living conditions, such as, multiple sclerosis, stroke, multiple trauma, AIDS, amputation, neurological disease, cancer, birth defect(s), or end stage renal disease;

ii. Debilitation or chronic illness causing progressive deterioration of self-care skills, such as, severe chronic disease, spina bifida, progressive pulmonary disease or diabetes;

iii. Multiple hospital admissions within the past six months not including patients admitted directly from NFs;

iv. Previous NF admissions within the past two years; or

v. Major health needs, that is, tube feedings, special equipment or treatments, rehabilitation/restorative services.

2. The social criteria are as follows: In addition to the medical criteria, does the patient meet any of the following social situations:

i. Homeless;

ii. Lives alone and/or has no immediate support system;

iii. Primary caregiver is not able to provide required care services; or

iv. Lack of adequate support systems.

3. The financial criteria are as follows. Does the patient meet any of the income and asset tests:

i. Currently eligible for Medicaid or NJ FamilyCare-Plan A;

ii. Monthly income at/or below the current institutional level specified at 10:71-5.6.

(1) Has no spouse in the community and resources no greater than those specified at 10:71-4.4 and 4.5;

(2) Has no spouse in the community and has resources at or below the maximum amount allowable, as determined by the Centers for Medicare & Medicaid Services (CMS) in accordance with the Medicare Catastrophic Coverage Act of 1988 (see N.J.A.C. 10:71). (This is an indication that the patient may become Medicaid or NJ FamilyCare-Plan A eligible within the next six months by spending down assets in an NF as private pay); or

(3) Has a spouse in the community with combined countable resources at or below the maximum amount allowable, as determined by CMS in accordance with the Medicare Catastrophic Coverage Act of 1988 (see N.J.A.C. 10:71).

iii. Monthly income at or below the current New Jersey Care . . . Special Medicaid programs maximum monthly income limit specified at 10:72-4.1 and:

(1) Has no spouse in the community and resources no greater than those specified at 10:71-4.4 and 4.5;

(2) Has no spouse in the community and resources at or below the maximum amount allowable, as determined by CMS in accordance with the Medicare Catastrophic Coverage Act of 1988 (see N.J.A.C. 10:71). This is an indication that the patient may become Medicaid or NJ FamilyCare-Plan A eligible within the next six months by spending down assets in an NF as private pay; or

(3) Has a spouse in the community with combined countable resources at or below the maximum amount allowable, as determined by CMS in accordance with the Medicare Catastrophic Coverage Act of 1988 (see N.J.A.C. 10:71).

(h) The hospital discharge planner or social worker shall be responsible for the discharge or placement arrangements of the patient.

1. For each hospital patient referred for PAS, the hospital shall complete and send to the OCCO a "Hospital Preadmission Screening Discharge form (LTC-8)."

i. For any patient discharged to a NF, a Discharge Package (HSDP, discharge paper work, DHSS approval letter, hospital transfer sheet and PASRR documentation, including any documentation which supports a diagnosis of Alzheimer's disease or related organic dementia) shall be compiled to accompany the patient to the NF.

(1) If the patient being transferred to a NF is eligible for Medicare benefits, the transfer shall be made to a Medicare/Medicaid participating NF.

ii. For those beneficiaries discharged to community locations, the hospital social worker or discharge planner shall be responsible for the implementation of the HSDP by securing home care services.

N.J. Admin. Code § 10:52-1.11

Recodified from N.J.A.C. 10:52-1.9 by R.1998 d.564, effective 12/7/1998.
See: 30 N.J.R. 1257(a), 30 N.J.R. 4225(a).
Former N.J.A.C. 10:52-1.10, Recordkeeping, recodified to N.J.A.C. 10:52-1.11.
Recodified from N.J.A.C. 10:52-1.10 and amended by R.2000 d.29, effective 1/18/2000.
See: 31 N.J.R. 3151(a), 32 N.J.R. 276(a).
Rewrote the section. Former N.J.A.C. 10:52-1.11, Recordkeeping, recodified to N.J.A.C. 10:52-1.12.
Amended by R.2005 d.214, effective 7/5/2005.
See: 37 N.J.R. 436(a), 37 N.J.R. 2506(a).
Rewrote the section.
Amended by R.2011 d.010, effective 1/3/2011.
See: 42 N.J.R. 1656(a), 43 N.J.R. 43(a).
Rewrote (b) through (f).