Fla. Admin. Code R. 59G-1.040

Current through Reg. 50, No. 235-239, December 10, 2024

Section 59G-1.040 - Preadmission Screening and Resident Review

(1) Purpose. This rule applies to all Florida Medicaid-certified nursing facilities (NF), regardless of payer source; all providers rendering NF services to Florida Medicaid recipients; and all entities that perform a function in the Preadmission Screening and Resident Review (PASRR) process as specified in this rule.

(2) Definitions.

(a) Hospital Discharge Exemption - Exception to the Level II evaluation and determination requirement prior to admission to an NF in accordance with Title 42, Code of Federal Regulations (CFR), section 483.106(b)(2)(i)(A)-(C).

(b) Intellectual Disability (ID) - As defined in 42 CFR 483.102(b)(3). The diagnosis of ID includes related conditions, i.e., individuals who have a severe, chronic disability that meets all of the following conditions:

1. Is attributable to one of the following:

a. Cerebral palsy or epilepsy.

b. Any other condition, (other than mental illness), found to be closely related to ID because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons diagnosed with ID, and requires treatment or services similar to those required for these persons.

2. Is manifested before the person reaches the age of 22 years.

3. Is likely to continue indefinitely.

4. Results in substantial functional limitations in three or more of the following areas of major life activity:

a. Self-care.

b. Understanding and use of language.

c. Learning.

d. Mobility.

e. Self-direction.

f. Capacity for independent living.

(c) Inter-Facility Transfer - The transfer of a resident from one NF to another NF.

(d) Level I PASRR Screen - Process to identify diagnosed or suspected ID, serious mental illness (SMI), or both, based on information gathered by the screener.

(e) Level II Evaluation and Determination - An in-depth, individualized, assessment of the individual to confirm whether the applicant to an NF has SMI, ID, or both; to assess the need for NF services; and evaluate what specialized services, if any, are needed.

(f) New Admission - An individual admitted to any NF for the first time, who was not readmitted or admitted as an inter-facility transfer.

(g) Preadmission Screening and Resident Review - Federal requirement mandated by 42 CFR 483.100-483.138.

(h) Readmission - When an NF resident is transferred to a hospital and returns to any NF within 90 calendar days.

(i) Resident Review (RR) - An evaluation and determination conducted by state-designated authorities when an NF resident experiences a significant change in his or her physical or mental status.

(j) Serious Mental Illness (SMI) - As defined in 42 CFR 483.102(b)(1).

(k) Significant Change - A decline or improvement in an NF resident's physical or mental status that is anticipated to require intervention.

(l) Specialized Services - Services specified by the state, or its designee, that are not covered in the NF per diem, and are required for appropriate placement in the NF setting for individuals with ID, SMI, or both.

(3) Level I PASRR Screen.

(a) The Agency for Health Care Administration (AHCA), or its designee, performs the Level I PASRR screens for all individuals seeking admission to an NF.

(b) The Agency for Health Care Administration delegates the following entities to perform Level I PASRR screens (collectively referred to as the Level I PASRR screeners):

1. Florida Department of Health (DOH) for individuals under the age of 21 years. The Department of Health may not further delegate Level I screening responsibilities.

2. Florida Department of Elder Affairs' (DOEA) Comprehensive Assessment and Review for Long-Term Care Services (CARES) program for individuals age 21 years and older. The CARES program may only delegate the Level I PASRR screen responsibility to hospital and NF staff who are licensed clinical social workers, physicians, physician assistants, registered nurses, mental health counselors, psychologists, or persons who hold a Master's Degree in Social Work.

(c) The Level I PASRR screen must be completed by the Level I PASRR screener prior to all new admissions to an NF, and within two business days of the request.

(4) Level II PASRR Evaluation Request.

Upon completion of the Level I PASRR screen, if the individual has a diagnosis of or suspicion of having an SMI, ID, or both:

(a) The Level I PASRR screener must send the individual or their legal representative, as applicable, written notice stating the individual has a diagnosis of, or is suspected of having, an SMI, ID, or both, and is being referred for a Level II PASRR evaluation.

(b) The AHCA-designated Level I PASRR screener must send all of the following documentation for a Level II PASRR evaluation to the Agency for Persons with Disabilities (APD), or the state's contracted vendor, for individuals diagnosed with, or suspected of having, an ID; or, to the state's contracted Level II PASRR evaluator for individuals diagnosed with, or suspected of having, an SMI:

1. Completed Preadmission Screening and Resident Review (PASRR) Level I Screen For Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID) (Level I PASRR Screen), AHCA MedServ Form 004 Part A, March 2017, incorporated by reference and available on AHCA's website at http://ahca.myflorida.com/Medicaid/review/index.shtml, and at https://www.flrules.org/Gateway/reference.asp?No=Ref-07931.

2. Informed consent, as documented on the Level I PASRR Screen, AHCA MedServ Form 004 Part A, March 2017, or the Preadmission Screening and Resident Review (PASRR) Resident Review (RR) - Evaluation Request For a Significant Change for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID) (Resident Review-Evaluation Request), AHCA MedServ Form 004 Part A1, March 2017, incorporated by reference and available on AHCA's website at http://ahca.myflorida.com/Medicaid/review/index.shtml, and at https://www.flrules.org/Gateway/reference.asp?No=Ref-07932.

3. AHCA 5000-3008 Form, incorporated by reference in Rule 59G-1.045, F.A.C.

4. Other medical documentation including history, most recent physical, relevant case notes or records of treatment and medication administration records, as applicable.

5. Psychiatric or psychological evaluation, if available.

6. An assessment conducted by CARES or the minimum data set (MDS), if applicable, if the individual is age 21 years and older.

7. An assessment conducted by DOH or the MDS, if applicable, if the individual is under the age of 21 years.

(5) The Level I PASRR screener must document the type of provisional admission an individual is seeking, if applicable, and ensure the individual is referred for a Level II evaluation and determination in accordance with subsection (6), as appropriate.

(6) Level II Evaluation Time Frames.

(a) A Level II evaluation must be finalized within seven business days of a completed Level II request if the Level I PASRR screen indicates a diagnosis, or suspicion of, SMI, ID, or both.

(b) Exceptions to the timeframe specified in paragraph (6)(a) are as follows:

1. Within seven calendar days after the delirium clears, in cases of delirium.

2. Within seven calendar days of admission for emergency admissions requiring protective services.

3. In advance of the expiration of the 14 days, when an individual is admitted to an NF for an in-home caregiver's respite in accordance with Section 400.172, Florida Statutes (F.S.), and is expected to remain in the facility for longer than a 14 calendar day stay, no more than twice in a calendar year.

4. By calendar day 40, when an individual is admitted to an NF under the hospital discharge exemption, and is expected to stay in the NF longer than 30 calendar days. In this instance, the NF must notify the AHCA-designated Level I screener on the 25th day of the individual's stay if the stay is expected to extend past 30 calendar days.

5. Prior to returning to the NF, when an individual with SMI, ID, or both, is transferred to the hospital from the NF, and the hospital stay is longer than 90 consecutive days.

(7) If the individual is not admitted to an NF within 30 calendar days of the Level II evaluation, another Level II evaluation must be completed.

(8) Level II Evaluation Entities and Components.

(a) The following entities are responsible for completing the Level II evaluation for applicants to an NF or residents referred for an RR (collectively known as the Level II evaluator):

1. State-contracted vendor for individuals diagnosed with, or suspected of having, an SMI.

2. Agency for Persons with Disabilities, or the state's contracted vendor, for individuals diagnosed with, or suspected of having, an ID.

(b) All Level II evaluations must involve the following:

1. Individual being evaluated and the legal representative, if appropriate.

2. Individual's family if the individual or the legal representative agrees to family participation.

(c) The Level II evaluation may be terminated if the evaluator determines at any time during the evaluation that the individual:

1. Does not have an SMI or ID.

2. Has a primary diagnosis of dementia.

3. Has a non-primary diagnosis of dementia without a primary diagnosis of SMI or ID.

(9) Level II Evaluation for Individuals with Diagnosis of, or Suspicion of Having, an SMI.

(a) A Level II evaluation for individuals with a diagnosis, or suspicion of having, an SMI must:

1. Confirm or rule out the diagnosis, or suspicion of, an SMI. A qualified mental health professional must review accurate and recent data of a comprehensive history and a physical examination, or perform or ensure performance of the same, including:

a. Complete medical history.

b. Review of all body systems.

c. Specific evaluation of the individual's neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes.

d. Additional evaluations conducted by appropriate specialists, where abnormal findings are the basis for an NF placement.

e. Comprehensive drug history including current or immediate past use of medications that could mask symptoms or mimic SMI.

f. Psychosocial evaluation of the person, including current living arrangements and medical and support systems.

g. Comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of SMI functioning, memory functioning, and orientation; description of current attitudes and overt behaviors; affect, suicidal or homicidal ideation, paranoia; and degree of reality testing (presence and content of delusions) and hallucinations.

2. Include a functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment must determine whether this level of support can be provided to the individual in an alternative community setting or whether the level of support needed is such that an NF placement is required. The functional assessment must address the individual's ability to:

a. Self-monitor health status.

b. Self-administer and schedule medical treatment (including medication compliance) or both.

c. Self-monitor nutritional status.

d. Handle money.

e. Dress appropriately.

f. Self-groom.

3. Confirm the need for NF services and recommend specialized services, if applicable.

(b) Specialized services for an SMI diagnosis are:

1. Services that are utilized to address an episode of SMI and that are rendered in an NF at levels required to avert or eliminate the need for inpatient psychiatric care.

2. Developed and supervised by a qualified mental health professional and include one or all of the following:

a. Psychiatric consultation and evaluation.

b. Psychotropic medication management.

c. Psychological evaluation.

d. Psychotherapy.

(10) Level II Evaluation for Individuals with Diagnosis, or Suspicion of Having, an ID.

(a) A Level II evaluation for individuals diagnosed with, or suspected of having, an ID must:

1. Confirm or rule out the diagnosis, or suspicion, of an ID. A licensed psychologist must identify the intellectual functioning measurement of individuals with an ID.

2. Confirm the need for NF services and recommend specialized services as necessary by assessing:

a. The individual's medical problems.

b. The level of impact these problems have on the individual's independent functioning.

c. All current medications used by the individual, and the current response of the individual to any prescribed medications in the following drug groups:

(I) Hypnotics.

(II) Antipsychotics (neuroleptics).

(III) Mood stabilizers and antidepressants.

(IV) Antianxiety-sedative agents.

(V) Anti-Parkinson agents.

d. Self-monitoring of health status.

e. Self-administering and scheduling of medical treatments, including medication compliance.

f. Self-monitoring of nutritional status.

g. Self-help development such as toileting, dressing, grooming, and eating.

h. Sensorimotor development such as ambulation, positioning, transfer skills, gross motor dexterity, visual motor perception, fine motor dexterity, hand-eye coordination, and extent to which prosthetic, orthotic, corrective, or mechanical supportive devices can improve the individual's functional capacity.

i. Speech and language (communication) development such as expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which non-oral communication systems can improve the individual's functional capacity, auditory functioning, and extent to which amplification devices (e.g., hearing aid) or a program of amplification can improve the individual's functional capacity.

j. Social development such as interpersonal skills, recreation-leisure skills, and relationships with others.

k. Academic or educational development, including functional learning skills.

l. Instrumental activities of daily living.

m. Vocational development, including present vocational skills.

n. Affective development such as ability to express emotions, make judgments and independent decisions.

o. The presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation such as the frequency and intensity of identified maladaptive or inappropriate behaviors.

(b) Specialized services for ID are directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible, and toward the prevention or deceleration of regression or loss of current optimal functional status. Specialized services for individuals with ID are:

1. Behavior analysis services, pursuant to Rule 65G-4.009, F.A.C.

2. Training services, to include:

a. Services intended to support the participation of recipients in daily, meaningful, valued routines of the community which may include work-like settings that do not meet the definition of supported employment.

b. Training in the activities of daily living, self-advocacy, and adaptive and social skills that are age and culturally appropriate. The service expectation is to achieve the goals defined by each individual or, if appropriate, the individual's legal representative. The training, activities, and routine established by the adult day training program must be meaningful to the individual and provide an appropriate level of variation and interest in accordance with a formal implementation plan that is developed under the direction of the individual or, if appropriate, the individual's legal representative.

(11) Level II Determination.

(a) The following entities are responsible for completing the Level II determination:

1. The Agency for Persons with Disabilities for individuals diagnosed with, or suspected of having, an ID.

2. The Department of Children and Families' (DCF) for individuals diagnosed with, or suspected of having, an SMI.

3. The Department of Children and Families is the lead agency in coordinating a joint determination with APD when the individual has a diagnosis of, or suspicion of having, both an SMI and an ID.

(b) The Level II determination must be issued in the form of a written summary report that:

1. Confirms or rules out SMI or ID.

2. Identifies the name and professional title of each person who performed the evaluation(s) and the date on which each portion of the evaluation was administered.

3. Summarizes the medical and social history, including the positive traits, developmental strengths and weaknesses, and developmental or mental health needs of the individual.

4. Identifies whether NF services and specialized services are needed.

5. Identifies any specific SMI or ID services the individual requires, including those of a lesser intensity when specialized services are not recommended.

6. Identifies placement options that are available to the individual, including whether the individual's needs could be met in a community setting, and what services would be needed for the individual to live in such a setting.

7. Documents the individual and legal representative, if appropriate, have been educated about all placement options (including information about the benefits of integrated settings), and that any concerns or objections raised by the individual or legal representative have been addressed.

8. Includes the basis for the summary report's conclusions.

9. Notifies the individual and legal representative of the right to appeal the determination.

10. Interprets and explains the summary report to the individual and legal representative.

(c) If the Level II evaluator rules out SMI or ID, the determination does not have to include the items indicated in subparagraphs (11)(b)4.-7., of this section.

(d) The Department of Children and Families or APD must send the completed determination summary with the notice of the administrative fair hearing process and the individual's rights to:

1. The evaluated individual and his or her legal representative, as appropriate.

2. The admitting or retaining NF.

3. The individual's attending physician.

4. The discharging hospital, if applicable.

5. The Level I screener appropriate to individual's age.

(12) Resident Review.

(a) The NF must notify CARES or DOH, as appropriate, when an NF resident who has, or is newly suspected of having, SMI, ID, or both, experiences a significant change that:

1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (for individuals experiencing a decline in condition).

2. Impacts more than one area of the resident's health status.

(b) The NF must submit all of the following documentation:

1. Completed AHCA MedServ Form 004 Part A1, March 2017.

2. Documented informed consent.

3. Level I PASRR screen.

4. Level II evaluation and determination or most recent RR, as applicable.

5. Long Term Care MDS or the most recent physical assessment, or an assessment provided by CARES or DOH.

6. Case notes.

7. Record of treatment.

8. Medication administration record.

9. Psychiatric or psychological evaluation, if available.

(13) Medicaid-certified nursing facilities must comply with 42 United States Code section 1396r(e)(7)(C), when a resident no longer requires NF services, but still requires specialized services, or no longer requires either NF services or specialized services.

(14) Consent for Level II Evaluation.

(a) If a Level II evaluation is required as a result of the Level I screen, or a resident review is required, written notice must be issued in accordance with 42 CFR 483.128(a) to individuals who have, or are suspected of having, SMI or ID, and are being referred to the state authorities for SMI or ID to perform the Level II evaluation. The signature of the individual being assessed, or their legal representative, must be obtained on AHCA MedServ Form 004 Part A1, March 2017, when possible as acknowledgement and consent for the Level II evaluation. Signing does not mean that the signator agrees with any determination(s).

(b) The signature is an acknowledgement of the signator's:

1. Opportunity to participate in decisions regarding the arrangements for continued care.

2. Acknowledgement of verbal and written information regarding the range of services in the assessed individual's community.

(c) If an individual is unwilling, or unable, to sign and has no legal representative or health care agent to sign, information regarding the reason for the inability to obtain the signature must be indicated on the Level I PASRR Screen, AHCA MedServ Form 004 Part A, March 2017, or Resident Review-Evaluation Request, AHCA MedServ Form 004 Part A1, March 2017.

(15) Records. Nursing facilities must maintain copies of all PASRR screenings, evaluations, re-evaluations, and determinations in the individual's file for the duration of his or her stay in the facility and for a period of five years after the individual has been discharged or transferred to another facility.

(16) Appeals. In accordance with state and federal law, an individual may request an appeal through the Medicaid fair hearing process if he or she believes the State has made an erroneous determination with regard to the preadmission and annual resident review processes.

Fla. Admin. Code Ann. R. 59G-1.040

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905(8), 409.912 FS.

New 12-31-13, Amended by Florida Register Volume 43, Number 050, March 14, 2017 effective 3/29/2017.

New 12-31-13, Amended 3-29-17.