Pa. Code tit. 55, pt. III, ch. 1181, subch. D, APPEALS OF ADVERSE DETERMINATIONS, app M
The Department is required to determine the need for nursing care and active treatment for all applicants to nursing homes who are mentally ill, mentally retarded or who have a related condition unless otherwise exempt.
For Departmental Determination of the applicant's need for nursing care and active treatment, the following information must be sent with the LAMP Summary and the PASARR-EV to the appropriate office listed in Appendix G. If a new evaluation or set of evaluations are required, those preparing their reports should address themselves to the following items.
I. Determination of All Persons. Data sent to the Department for determination of need for nursing care for all persons must include:
A. The finding that the applicant's medical needs cannot be adequately met in noninstitutional settings include at least:
1. An evaluation of medical status including at least the applicant's:
a. Diagnoses.
b. Date of onset.
c. Medical history.
d. Prognosis.
2. A history of previous rehabilitation within the past year.
B. A recommendation based upon medical determination that nursing care is needed.
II. Determination of Persons with Mental Illness. Data sent to the Department for determinations to be made for persons with mental illness must also include a recommendation and sufficient supporting information in order to determine whether or not the person needs the implementation of "active treatment" in order to be able to function. Information must include:
A. A comprehensive history and physical examination of the person. At a minimum, the examination must address the following areas-if not previously addressed:
1. Complete medical history.
2. Review of all body systems.
3. Specific evaluation of the person's neurological system in the areas of:
a. Motor functioning.
b. Sensory functioning.
c. Gait.
d. Deep tendon reflexes.
e. Cranial nerves.
f. Abnormal reflexes.
4. In case of abnormal findings which are the basis for a nursing facility placement, additional evaluations must be conducted by appropriate specialists.
5. If the history and physical examination used for the PASARR Determination is not performed by a physician, then a physician's countersignature is required.
B. A comprehensive drug history of all current or immediate past utilization of medications used by the person that could mask symptoms, as well as the use of medications that could mimic mental illness.
C. A psychosocial evaluation of the person. At a minimum, this includes an evaluation of the following:
1. Current living arrangements.
2. Medical and support systems.
3. If the psychosocial evaluation is not conducted by a social worker, then a social worker's countersignature is required.
D. A comprehensive mental health evaluation. At a minimum, the evaluation must address the following areas:
1. Complete mental health history.
2. Evaluation of intellectual functioning, memory functioning, and orientation.
3. Description of current attitudes and overt behaviors.
4. Affect.
5. Suicidal/homicidal ideation.
6. Degree of reality testing-presence and content of delusions-and hallucinations.
7. If the mental health evaluation is not performed by a physician who is knowledgeable about mental illness or a clinical psychologist. Then the countersignature of one or the other is required.
E. The information must include all medical and psychiatric diagnoses which require treatment. Copies of previous discharge summaries-during the past 2 years.
III. Determination of Persons with Mental Retardation or Related Conditions. Data sent to the Department for determination to be made for persons with mental retardation or other related conditions must also include a recommendation and sufficient supporting information to determine whether or not the person needs the implementation of a continuous "active treatment" program as defined at 42 CFR 435.1009"Active Treatment in Intermediate Care Facilities for the Mentally Retarded" in order to be able to function. Information must include:
A. The individual's comprehensive history and physical examination results so that the following, minimum information can be identified:
1. A list of the individual's medical problems.
2. The level of impact these problems have on the individual's independent functioning.
3. A list of all current medications used by the individual.
4. Current response of the individual to any prescribed medications in the following drug groups:
a. Hypnotics.
b. Antipsychotics (neuroleptics).
c. Mood stabilizers and antidepressants.
d. Antianxiety-sedative agents.
e. Anti-parkinsonian agents.
B. An assessment of the individual's:
1. Self-monitoring of health status.
2. Self-administering and/or scheduling of medical treatments.
3. Self-monitoring of nutrition status.
4. Self-help development-such as: toileting, dressing, grooming and eating.
5. Sensorimotor development-such as: ambulation, positioning, transfer skills, gross motor dexterity, visual motor/perception, fine motor dexterity, eye-hand coordination and extent to which prosthetic, orthotic, corrective or mechanical supportive devices can improve the individual's functioning capacity.
6. Speech and language (communication) development-such as: expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which nonoral communication systems can improve the individual's functional capacity, auditory functioning and extent to which amplification devices (hearing aid) or a program amplification can improve the individual's functional capacity.
7. Social development, such as: interpersonal skills, recreation-leisure skills and relationships with others.
8. Academic/educational development, including functional learning skills.
9. Independent living development-such as: meal preparation, budgeting and personal finances, survival skills, mobility skills (orientation to the neighborhood, town, city), laundry, housekeeping, shopping, bedmaking, care of clothing, and orientation skills-for individuals with visual impairments.
10. Vocational development, including present vocational skills.
11. Affective development-such as: interests and skills involved with expressing emotions, making judgements and making independent decisions.
12. Presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation-including, but not limited to, the frequency and intensity of identified maladaptive or inappropriate behaviors.
C. The information conveyed to the Department must identify to what extent the person's status compares with each of the following characteristics, commonly associated with need for active treatment:
1. Inability to take care of most personal care needs.
2. Inability to understand simple commands.
3. Inability to communicate basic needs and wants.
4. Inability to be employed at a productive wage level without systematic long term supervision or support.
5. Inability to learn new skills without aggressive and consistent training.
6. Inability to apply skills learned in a training situation to other environments or settings without aggressive and consistent training.
7. Without direct supervision, inability to demonstrate behavior appropriate to the time, situation or place.
8. Demonstration of severe maladaptive behaviors which place the person or others in jeopardy to health and safety.
9. Inability or extreme difficulty in making decisions requiring informed consent.
10. Presence of other skill deficits or specialized training needs which necessitates the availability of trained Mental Retardation personnel, 24 hours per day, to teach the person to learn functional skills.
D. The information must indicate that a psychologist, who meets the qualifications of a Qualified Mental Retardation Professional, as defined in 42 CFR 483.430(a)(1)(2):
1. Identifies the individual's intellectual functioning measurement.
2. Validates the individual has mental retardation or a related condition.
3. Recommends whether the individual needs active treatment to function.
Pa. Code tit. 55, pt. III, ch. 1181, subch. D, APPEALS OF ADVERSE DETERMINATIONS, app M
This appendix cited in 55 Pa. Code § 1181.544 (relating to where and how evaluations will be made); and 55 Pa. Code § 1181.546 (relating to how providers and applicants will be notified).