N.M. Admin. Code § 8.312.2.18

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.312.2.18 - PRE-ADMISSION SCREENING AND RESIDENT REVIEW (PASRR) OF MENTALLY ILL AND INTELLECTUALLY DISABLED INDIVIDUALS

As part of the initial NF communication form for a new admission or as part of a subsequent specified review as determined by PASRR, or a significant change review as indicated by the minimum data set (MDS) for an eligible recipient or member resident with identified mental illness or is intellectually disabled, the NF must complete a level I PASRR screening. See Omnibus Reconciliation Acts of 1987 and 1990 as codified at 42 CFR Section 483.100 Subpart C. See also P.L. 104-315 which amends title XIX of the Social Security Act effective October 19, 1996. This requirement applies to all applicants or residents, regardless of payment source.

A.Pre-admission screens not required: Pre-admission screens do not need to be performed on the following eligible recipient or member resident:

(1) when admitted from the hospital whose attending physicians certify before admission to the NF that the eligible recipient or member resident is likely to require NF care for less than 30 days (as determined by PASRR review of the his or her level I screen data which was done prior to NF admission);

(2) when readmitted to NFs from a hospital to which he or she was transferred for the purpose of receiving care; and

(3) when transferred from one NF to another without an intervening hospital stay.

B.Purpose of the screens: The purpose of the PASRR screen is to determine whether residents have a mental illness or an intellectual disability, need the level of services furnished in a NF and need specialized services based on the mental illness or intellectual disability. A NF performs the level I screen which identifies an eligible recipient or member resident who has a mental illness or an intellectual disability. When an eligible recipient or member resident is identified, the NF refers him or her to the DOH DDSD for a PASRR level II evaluation.

C.Level II screen determination: The PASRR level II screen determines the following:

(1) the eligible recipient or member resident's total needs are such that his or her needs can be met in an appropriate community setting;

(2) the eligible recipient or member resident's total needs are such that they can be met only on an inpatient basis, which can include the option of placement in a home and community-based service waiver program, but for which inpatient care is necessary;

(3) if inpatient care is appropriate and desired, the NF is an appropriate institutional setting for meeting those needs; or

(4) if inpatient care is appropriate and desired but the NF is not the appropriate setting for meeting the eligible recipient or member resident's needs, another setting, such as an intermediate care facility for individuals with intellectual disabilities (ICF-IID) can be indicated.

D.Right to an administrative hearing: An individual who has been adversely affected by the preadmission screening or resident review screening is entitled to a HSD administrative hearing. See 8.354.2 NMAC for a detailed description of this specific type of HSD administrative hearings.

(1) An eligible recipient or member or his or her authorized representative may request a HSD administrative hearing.

(2) MAD, the MCO or their designees do not pay fees or costs, including attorney's fees, incurred by the individual or his or her authorized representative as a result of a HSD pre-hearing conference or a HSD administrative hearing, or if he or she files an appeal of the HSD administrative hearing final decision.

E.Restriction on reimbursement for medicaid residents: A NF is not reimbursed for any service furnished to an eligible recipient or member resident when pre-admission screens, subsequent specified reviews or significant change reviews are not performed in a timely manner. MAD or the MCO pays only for services furnished after the screens or reviews are performed and will recoup amounts paid to a NF during periods of noncompliance. MAD or the MCO payment for services does not begin until a level II screening has been performed, if applicable.

N.M. Admin. Code § 8.312.2.18

8.312.2.18 NMAC - Rp, 8.312.2.18 NMAC, 8/1/14