N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-2.30

Current through Register Vol. 46, No. 45, November 2, 2024

Section 86-2.30 - Residential health care facilities patient assessment for certified rates

(a) For the purpose of determining reimbursement rates effective January 1, 1986 and thereafter, for governmental payments, each residential health care facility shall, on an annual basis or more often as determined by the department pursuant to this Subpart, assess all patients to determine case mix intensity using the patient review criteria and standards promulgated and published by the department (patient review instrument [PRI] and instructions: patient review instrument) and specified in subdivision (i) of this section.

(b)

(1) The patient review form (PRI) shall be submitted according to a written schedule determined by the department. Such written schedule shall be established by the Commissioner of Health with notice to residential health care facilities. Extension of the time for filing may be granted upon application received prior to the due date of the patient review forms and only in circumstances where the residential health care facility establishes, by documentary evidence, that the patient review forms cannot be submitted by the due date for reasons beyond the control of the facility.

(2) Rate schedules shall not be certified by the Commissioner of Health unless residential health care facilities are in full compliance with the requirements of this section. Compliance with the assessment requirements of this section shall include, but not be limited to, the timely filing of properly certified patient review forms (PRI) which are complete and accurate. Failure of a residential health care facility to file the patient review form (PRI) pursuant to the written schedule established pursuant to this subdivision, shall subject the residential health care facility to the provisions of section 86-2.2(c) of this Subpart.

(c) The operator of a residential health care facility shall ensure:

(1) that the patient review form (PRI) is completed for all patients of the facility pursuant to subdivision (a) of this section;

(2) that the patient review form (PRI) is completed by a registered professional nurse who is qualified by experience and demonstrated competency in long-term care and who has successfully completed a training program in patient case mix assessment approved by the department to train individuals in the completion of the patient review form (PRI) for the purposes of establishing a facility's case mix financial reimbursement; and

(3) that the patient review form (PRI) is certified by the operator and the nurse assessor responsible for completion of the patient review form (PRI). (The form of the certification required shall be as prescribed in the report form provided by the department.)

(d) In order to maximize reliability and accuracy, a limited number of personnel for each residential health care facility may be responsible for completion of the patient review form (PRI) during each assessment period. The maximum number of personnel which may be responsible in each residential health care facility is as follows:

Bed size of facility	Number of responsible assessors
Under 100	Two
101 to 200	Three
201 to 300	Four
301 to 400	Five
401+	Five plus one additional assessor for each additional 100 beds or part thereof.

(e)

(1) The department shall monitor and review each residential health care facility's performance of its patient assessment function as described in this section through the following activities which may include, but shall not be limited to:

(i) analysis of patient case mix profiles and statistical data;

(ii) review of information provided by the residential health care facility; and

(iii) on-site inspections.

(2) The purpose of the department's monitoring and review shall be to determine whether the residential health care facility is complying with the assessment requirements contained in this section.

(3) The patient review form (PRI) and any underlying books, records, and/or documentation which formed the basis for the completion of such form shall be subject to review by the department.

(4) The department shall acknowledge, in writing, receipt of the residential health care facilities patient review forms (PRI). In the event that any information or data that the facility has submitted is inaccurate or incorrect, the facility shall correct such information or data in the following manner: the facility shall submit to the department, within five days of receipt of the department's written acknowledgment provided for in this paragraph, such corrections on a form which meets the same certification requirements as the document being corrected. Once receipt of corrected data is acknowledged in writing by the department, a residential health care facility may not correct or amend the patient review form (PRI) or submit any additional information for the assessment period.

(5) The department, in order to ensure accuracy of the patient review form (PRI), may also conduct timely on-site observations and/or interviews of patients/residents and review of their medical records. When an additional on-site review is performed by the department as a result of controverted items found during the initial on-site review, the facility shall be afforded an on-site conference prior to the conclusion of such additional on-site review. Upon completion of a department on-site review pursuant to this subdivision, the department, in order to ensure accuracy of the patient review form (PRI), shall correct, where necessary, a residential health care facility's assessment of its patient case mix intensity. The department's on-site determination shall be considered final for purposes of assessing the residential health care facility's case mix intensity for that assessment period and notwithstanding section 186-2.14 of this Subpart, the residential health care facility may not correct or amend the patient review form (PRI) or submit any additional information after department reviewers have concluded the on-site review. The residential health care facility shall be notified in writing regarding the department determination of any controverted items.

(f)

(1) If the department determines pursuant to this section, that a residential health care facility is not performing its case mix intensity assessment function in a timely and/or accurate manner, as required by subdivision (b) of this section, the department shall, in writing:

(i) notify the residential health care facility;

(ii) require the residential health care facility to perform its patient case mix assessment function through written agreement with a person or entity approved by the department for the completion of the patient review form (PRI) for the purpose of establishing a residential health care facilities case mix reimbursement; and

(iii) any patient case mix assessment performed pursuant to subparagraph (ii) of this paragraph shall also be subject to department monitoring and review pursuant to this section.

(2) The department shall determine that a residential health care facility is not performing its case mix intensity assessment function in an accurate manner where there exists inaccuracies in its case mix assessment which results in a statistically significant modification of the residential health care facility's reimbursement.

(3) The cost of written agreements required by paragraph (1) of this subdivision shall not be considered an allowable cost for determining reimbursement rates pursuant to this Subpart.

(4) Certification. Operators of residential health care facilities completing the department's patient review form (PRI) through written agreement with a department approved nonresidential health care facility person or entity shall have such form certified by such person or entity in lieu of a residential health care facility registered professional nurse as required by paragraph (c)(2) of this section.

(g)Reconsiderations.

(1) Any residential health care facility after one year from the date it has been notified in writing by the department that it must enter into a written agreement pursuant to paragraph (f)(1) of this section, may request, in writing, that the department rescind its withdrawal of the residential health care facility's patient case mix assessment function.

(2) The department shall not rescind its withdrawal of a residential health care facility's patient case mix assessment function unless the residential health care facility satisfies the department that the residential health care facility has the capability to comply with the requirements of the department's patient case mix assessment process which shall include the capability to accurately complete the patient review form (PRI).

(3) The department shall give written notice of its decision and shall, if negative, give a statement of the reasons for its refusal to rescind its withdrawal of the residential health care facility's patient case mix assessment function.

(4) Any residential health care facility after six months from the date it receives a written department decision pursuant to paragraph (3) of this subdivision, may again request in writing that the department rescind its withdrawal of the residential health care facility's patient case mix assessment function.

(i)Forms.

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NEW YORK STATE DEPARTMENT OF HEALTH

DIVISION OF HEALTH CARE FINANCING

INSTRUCTIONS: PATIENT REVIEW INSTRUMENT (PRI)

GENERAL CONCEPTS

1. USING THESE INSTRUCTIONS: These instructions and the training manual should be read before completing the PRI. These instructions should be kept with the PRIs as they are being completed. FREQUENT REFERENCE TO THE INSTRUCTIONS WILL BE NEEDED TO COMPLETE THE PRI ACCURATELY.

2. ANSWER ALL QUESTIONS: Answer all questions using the numeric codes provided. DO NOT LEAVE ANY QUESTIONS TOTALLY BLANK. UNUSED BOXES FOR A QUESTION SHOULD REMAIN BLANK. For example, Medical Record Number should be entered: /9/6/2/1/0/. If there are unused boxes, they should be on the left side of the number as shown in the example.

3. QUALIFIERS: Many of the PRI questions contain multiple criteria which are labeled qualifiers. All qualifiers must be met for a question to be answered yes. These qualifiers take the following forms:

* TIME PERIOD -The time period for the questions is the past four weeks, unless stated otherwise. For patients who have been in the facility less than four weeks (that is, new admissions or readmissions), use the time for admission to PRI completion as the time frame.

* FREQUENCY -The frequency specifies how often something needs to occur to meet the qualifier. For example, respiratory care needs to occur daily for four weeks or the PRI cannot be checked for this patient as receiving this care.

* DOCUMENTATION -Some of the questions require specific medical record documentation to be present. Otherwise, the question cannot be answered "yes" for the patient.

* EXCLUSIONS- Some of the questions specifically state to omit certain types of care or behavior when answering the question. For example, inhalators are excluded from respiratory care.

4. ACTIVITIES OF DAILY LIVING: The approach to measuring ADLs is slightly different from the other PRI questions. Measure the ADLs according to how the activity was completed 60 percent or more of the time during the past four weeks. Read the specific instructions for ADLs to understand the CHANGED CONDITION RULE and other details. PERFORMANCE: Measure what the patient does, rather than what the patient might be capable of doing.

5. CORRECTIONS: Cross out any responses which you wish to change and reenter clearly to the right of the original response. Example: /3/4.

6. Use pen, not pencil.

INSTRUCTIONS: PRI QUESTIONS

I. ADMINISTRATIVE DATA

1. OPERATING CERTIFICATE NUMBER: Enter the 8 character identifier (7 numbers followed by the letter "N") stated on the facility's operating certificate. The last character "N" indicates Nursing Facility.

2. SOCIAL SECURITY NUMBER: Your PRIs cannot be processed unless this question is accurately entered. Do not leave this question blank, do not enter zero if there is no social security number. Only use the Social Security number that has been specifically designated for the patient and not the spouse of the patient. Only use the number that has been assigned by the federal Social Security Administration. If there is no such number for a patient, a NEW SYSTEM has been developed to enable all facilities in the State to assign a unique ID number to those patients without a Social Security number. If a patient was assigned a computer generated number by the Department, that number should no longer be used. If the patient has no Social Security number, use this method: Enter the first three (3) letters of the patient's last name (starting to the far left), and then enter the six digits of the patient's date of birth. Omit the century in the birthdate, which will be either a "19" or "18" as in 1930 or 1896. As an example, if a patient named Cheryl Brant has no social security number and was born on May 8, 1913, you would enter: /B/R/A/0/5/0/8/1/3 on the PRI.

3. RESIDENT IS LOCATED: Former HRF Area or Former SNF Area. This question has been revised to reflect the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). It is imperative that nursing facilities formerly deemed "dual level" complete this section properly.

4. PATIENT NAME: Enter the patient's name, last name first, in the boxes provided. Enter up to the first 10 letters of the patient's last name.

6. MEDICAL RECORD NUMBER: Enter the unique number assigned by the facility to identify each patient. It is not the Medicaid, Medicare or Social Security number unless that is the number used by the facility to identify each of its patients.

7. ROOM NUMBER: Enter the numbers and/or letters which identify the patient's room in the facility.

8. UNIT NUMBER: Enter the one or the two digit number (01-12) assigned by your facility to each nursing unit for the purpose of this data collection.

11. DATE OF INITIAL ADMISSION: Enter the month, day and year the patient (1) entered the present nursing facility. Use the date of the patient's first admission and not the most recent. If the patient were transferred from another facility, it would be an initial admission to your facility. As another example, consider a patient that was admitted to a hospital from your facility and subsequently loses bed hold. If this patient is eventually readmitted to your facility at the original level of care, use the original admission date to complete this item.

12. MEDICAID NUMBER: Enter these numbers if patient has the coverage available, whether

13. MEDICARE NUMBER: or not the coverage is being used. If not, enter only one zero in the far right box.

14. PRIMARY PAYOR: Enter the one source of coverage which pays for most of the patient's current nursing home stay. Code "Other" only if the primary payor is not Medicaid or Medicare. (Do not code "Other" for a patient with Medicaid coverage supplemented by Medicare Part B Code Medicaid.) Medicaid pending is to be coded as "Medicaid", if there is no other primary coverage being used for the patient's present stay.

15A. REASON FOR PRI COMPLETION: Select the one reason why the PRI is being completed. Responses 3, 4, and 5 under Utilization Review have been eliminated.

REIMBURSEMENT ASSESSMENT CYCLE:

Indicate whether this assessment is being completed as a part of a full facility assessment or as part of a quality assessment cycle for new admissions only.

1. Biannual Full Facility Cycle-The data collection during which all the patients residing in the facility are assessed. These PRI assessments include patients who were assessed during your previous PRI data collection and any new admissions.

2. Quarterly New Admission Cycle-The "new admission only data collection," involving only patients who were not assessed at their present level of care during your previous full facility data collection are reviewed. This specific PRI data collection occurs three months after your full facility PRI data collection. A new admission may be a new patient from the hospital, community or another nursing facility; or was hospitalized during your previous full facility assessment (regardless of bedhold).

15B. WAS A PRI SUBMITTED BY YOUR FACILITY FOR THIS PATIENT DURING A PREVIOUS FULL FACILITY AND/OR NEW ADMIT CYCLE: Review your facility's records to determine whether a PRI for reimbursement purposes was ever completed for this patient.

II. MEDICAL EVENTS

16. DECUBITUS LEVEL: Enter the level of skin breakdown (located at pressure points) using the qualifiers stated below:

Documentation -	For a patient to be cited as level 4, documentation by a licensed clinician must exist which describes the following three components:
* A description of the patient's decubitus.
* Circumstance or medical condition which led to the decubitus.
* An active treatment plan.
Definition
LEVELS:	#0 No reddened skin or breakdown.
#1 Reddened skin, potential breakdown.
#2 Blushed skin, dusty colored, superficial layer of broken or blistered skin.
#3 Subcutaneous skin is broken down.
#4 Necrotic breakdown of skin and subcutaneous tissue which may involve muscle, fascia and bone.
#5 Patient is at level 4, but the documentation qualifier has not been met.

17. MEDICAL CONDITIONS: For a "YES" to be answered for any of these conditions, all of the following qualifiers must be met:

Time Period -	Condition must have existed during the past four weeks. (The only exception is to use the past twelve weeks for question 17H, urinary tract infection.)
Documentation -	Written support exists that the patient has the condition.
Definitions -	See chart below. (Examples are for clarification and are not intended to be all- inclusive.)

DEFINITION	EXAMPLES OF CAUSES	EXAMPLES OF TREATMENTS
17A. COMATOSE: Unconscious, cannot be aroused, and at most can respond only to powerful stimuli. The coma must be present for at least four days.	Brain insult Hepatic encephalopathy Cerebral vascular accident	Total ADL Care Intake & output Parenteral feeding
17B. DEHYDRATION: Excessive loss of body fluids requiring immediate medical treatment and ADL care.	Fever Acute urinary tract infections Pneumonia Vomiting Unstable diabetes	Intake & output Electrolyte lab tests Parenteral hydration Nasal feedings
17C. INTERNAL BLEEDING: Blood loss stemming from a subacute or chronic condition (e.g., gastrointestinal, respiratory or genito-urinary conditions) which may result in low blood pressure and hemoglobin, pallor, dizziness, fatigue, rapid respiration.	Use only the causes presented in the definition. Exclude external hemorrhoids and other minor blood loss which is not dangerous and requires only minor intervention	Critical monitoring of vital signs Transfusion Use of blood pressure elevators Plasma expanders Blood likely to be needed every 60 days
17D. STASIS ULCER: Open lesion, usually in lower extremities, caused by decreased blood flow from chronic venous insufficiency.	Severe edema Diabetes PVD	Sterile dressing Compresses Whirlpool Leg elevation
17E. TERMINALLY ILL: Professional prognosis (judgment) is that patient is rapidly deteriorating and will likely die within three months.	End stages of: Carcinoma, Renal disease, and Cardiac diseases	ADL Care Social/emotional support
17F. CONTRACTURES: Shortening and tightening of ligaments and muscles resulting in loss of joint movement. Determine whether range of motion loss is actually due to spasticity, paralysis or joint pain. It is important to observe the patient to confirm whether a contracture exists and check the chart for confirmatory documentation.
To qualify as "YES" on the PRI the following qualifiers must be met:
1. The contracture must be documented by a physician, physical therapist or occupational therapist.
2. The status of the contracture must be reevaluated and documented by the physician, physical therapist or occupational therapist on an annual basis.
There does not need to be an active treatment plan to enter "YES" to contractures.
17G. DIABETES MELLITUS: A metabolic disorder in which the ability to oxidize carbohydrates is compromised due to inadequate pancreatic activity resulting in disturbance of normal insulin production. This may or may not be the primary problem (Q. 29) or primary diagnosis. It should be diagnosed by a physician. Include any degree of diabetes, stable or unstable, and any manner it is controlled.	Destruction/malfunction of the pancreas Exclude hypoglycemia or hyperglycemia which may be a diabetic condition, but by itself does not constitute diabetes mellitus.	Special diet Oral agents Insulin Exercise
17H. URINARY TRACT INFECTION: During the past twelve weeks symptoms of a UTI have been exhibited or it has been diagnosed by lab tests. Symptoms may include frequent voiding, foul smelling urine, voiding small amounts cloudy urine, sediment and an elevated temperature. May or may not be the primary problem under Q. 29. Include as a UTI if it has not been confirmed yet by lab tests, but the symptoms are present. Include patients who appear asymptomatic, but whose lab values are positive (e.g., mentally confused or incontinent patients).	Exclude if symptoms are present, but the lab values are negative	Antibiotics Fluids
17I. HIV INFECTION SYMPTOMATIC: HIV (Human Immunodeficiency Virus) Infection, Symptomatic: Includes Acquired Immunodeficiency Syndrome (AIDS) and HIV related illnesses. The patient has been tested for HIV infection AND a positive finding is documented AND the patient has had symptoms, documented by a physician, nurse practitioner (in conformance with a written practice agreement with a physician), or physician assistant as related to the HIV infection. Symptoms include but are not limited to abnormal weight loss, respiratory abnormalities, anemia, persistent fever, fatigue and diarrhea. Symptoms need not have occurred in the past four weeks. Exclude patients who have tested positive for HIV infection and have not become symptomatic, and patients who have not received the results of the HIV test.
17J. ACCIDENT: An event resulting in serious bodily harm, such as a fracture, a laceration which requires closure, a second or third degree burn or an injury requiring admission to a hospital.
To qualify as "YES" on the PRI the following qualifier must be met:
1. During the past six months serious bodily harm occurred as the result of one or more accidents.
17K. VENTILATOR DEPENDENT: A patient who has been admitted to a skilled nursing facility on a ventilator or has been ventilator dependent within five (5) days prior to admission to the skilled nursing facility. Patients who are in the process of being weaned off of ventilator support will qualify for this category for one month after extubation if they are receiving active respiratory rehabilitation services during that period. Patients in the facility who decompensate and require intubation also qualify for this category.

All services shall be provided in accordance with sections 416.13, 711.5 and 713.21 of Chapter V of Title 10 of the Official Compilation of Codes, Rules and Regulations of the State of New York.

18. MEDICAL TREATMENTS: For a "YES" to be answered for any of these, the following qualifiers must be met:

Time Period -	Treatment must have been given during the past four weeks in conformance with the frequency requirements cited below and still be required. For medical treatments having a daily frequency requirement, treatment must be provided every day of the four week period, except for residents newly admitted during the period. For residents newly admitted during the four week period, treatments required daily must have been provided each day from admission to the end of the four week period and documentation must support the seriousness of the condition and the probability that treatment will continue for at least four weeks.
Frequency -	As specified in the chart below. (The only exception is to use the past twelve weeks for question 18L, catheter.)
Documentation -	Physician order, nurse practitioner order (in conformance with a written practice agreement with a physician), or appropriately cosigned physician assistant order specifies that treatment should be given and includes frequency as cited below, where appropriate.
Exclusions -	See chart below.

DEFINITION	SPECIFIC FREQUENCY	EXCLUSIONS
18A. TRACHEOSTOMY CARE: Care for a tracheostomy, including suctioning. Exclude any self-care patients who do not need daily staff help.	Daily	Self-care patients
18B. SUCTIONING: Nasal or oral techniques for clearing away fluid or secretions. May be for a respiratory problem.	Daily	Any tracheostomy Suctioning
18C. OXYGEN THERAPY: Administration of oxygen by nasal catheter, mask (nasal or oronasal), funnel/cone, or oxygen tent for conditions resulting from oxygen deficiency (e.g., cardiopulmonary condition).	Daily	Inhalators Oxygen in room, but not in use
18D. RESPIRATORY CARE: Care for any portion of the respiratory tract, especially the lungs (for example COPD, pneumonia). This care may include one or more of the following: percussion or cupping, postural drainage, positive pressure machine, possibly oxygen to administer drugs, etc.	Daily	Suctioning
18E. NASAL GASTRIC FEEDING: Primary food intake is by a tube inserted into nasal passage; resorted to when it is the only route to the stomach.	None	None Gastrostomy not applicable
18F. PARENTERAL FEEDING: Intravenous or subcutaneous route for the administration of fluids used to maintain fluid, nutritional intake, electrolyte balance (e.g., comatose, damaged stomach).	None	None Gastrostomy not applicable
18G. WOUND CARE: Subcutaneous lesion(s) resulting from surgery, trauma, or open cancerous ulcers.	Care has been provided or is professionally judged to be needed for at least 3 consecutive weeks	Decubiti Stasis ulcers Skin tears Feeding tubes
18H. CHEMOTHERAPY: Treatment of carcinoma through IV and/or oral chemical agents, as ordered by a physician, nurse practitioner (in conformance with a written practice agreement with a physician), or physician assistant when the physician assistant's order is appropriately cosigned. (Patient may have to go to a hospital for treatment.)	None	None
18I. TRANSFUSIONS: Introduction of whole blood or blood components directly into the blood stream. (Patients may have to go to a hospital for treatment.)	None	None
18J. DIALYSIS: The process of separating components, as in kidney dialysis (e.g., renal failures, leukemia, blood dyscrasia). Patient may have to go to a hospital for treatment.	None	None
18K. BOWEL AND/OR BLADDER REHABILITATION: The goal of this treatment to gain or regain optimal bowel and/or bladder function and to reestablish a pattern. It is much more than just a toileting schedule or a maintenance/conditioning program. Rather it is an intense treatment which is very specific and unique for each patient and is of short term duration (i.e., usually not longer than six weeks). NOT all patients at level 5 under Toileting Q. 22 may be a "YES" with this question. The specific definition for bladder rehabilitation differs from bowel rehabilitation; refer below:	Very specific and unique for each patient	Maintenance toileting schedule Restorative toileting program but does not meet the treatment requirements specified in the definitions
Bladder rehabilitation: Will generally include these step-by-step procedures which are closely monitored, evaluated and documented: (1) mental and physical assessment of the patient to determine training capacity; (2) a 24 hour flow sheet or chart documenting voiding progress; (3) possibly increased fluid intake during the daytime; (4) careful attention to skin care; (5) prevention of constipation; (6) in the beginning may be toileted 8 to 12 times per day with decreased frequency with progress.
Bowel rehabilitation: A program to prevent chronic constipation/impaction. The plan will generally include: (1) assessment of past bowel movements, relevant medical problems, medication use; (2) a dietary regimen of increased fluids and bulk (e.g., bran, fruits); (3) regular toileting for purposes of bowel evacuation; (4) use of glycerine suppositories or laxatives; (5) documentation on a worksheet or Kardex.	Exclude a bowel maintenance program which controls bowel intinence by development of a routine bowel schedule
18L. CATHETER: During the past twelve weeks, an indwelling or external catheter has been needed. Indwelling catheter has been used for any duration during the past twelve weeks. The external catheter was used on a continuous basis (with proper removal and replacement during this period) for one or more days during the past twelve weeks. A physician order is required for an indwelling catheter; for an external catheter a physician order is not required.	Exclude catheters used to empty the bladder once, secure a specimen or instill medication
18M. PHYSICAL RESTRAINTS: A physical device used to restrict resident movement. Physical restraints include belts, vests, cuffs, mitts, jackets, harnesses and geriatric chairs.	At least two continuous daytime hours for at least 14 days during the past four weeks.	Exclude all of following: " Medication use for the sole purpose of modifying residents behavior
" Application only at night
" Application for less than two continuous daytime hours for 14 days
" Devices which residents can release/ remove such as, velcro seatbelts on wheelchairs
" Residents who are bed bound
" Side rails, locked doors/ gates, domes
To Qualify as "YES" on the PRI the following qualifiers must be met:
1. The restraint must have been applied for at least two continuous daytime hours for at least 14 days during the past four weeks. Daytime includes the time from when the resident gets up in the morning to when the resident goes to bed at night.
2. An assessment of need for the physical restraint must be written by an M.D. or R.N.
3. The comprehensive care plan based on the assessment must include a written physician's order and specific nursing interventions regarding use of the physical restraint.
NEW ADMISSIONS: If a patient is a new admission and will require the use of a physical restraint for at least two continuous daytime hours for at least 14 days as specified by the physician order, then enter "YES" on the PRI.

III. ACTIVITIES OF DAILY LIVING: EATING, MOBILITY, TRANSFER, TOILETING

Use the following qualifiers in answering each ADL question:

Time Period -	Past four weeks.
Frequency -	Assess how the patient completed each ADL 60 percent or more of the time performed (since ADL status may fluctuate during the day or over the past four weeks).
CHANGED CONDITION RULE: When a patient's ADL has improved or deteriorated during the past four weeks and this course is unlikely to change, measure the ADL according to its status during the past seven days.
Definitions -	SUPERVISION means verbal encouragement and observation, not physical hands- on care.
ASSISTANCE means physical hands-on care.
INTERMITTENT means that a staff person does not have to be present during the entire activity, nor does the help have to be on a one-to-one basis.
CONSTANT means one-to-one care that requires a staff person to be present during the entire activity. If the staff person is not present, the patient will not complete the activity.
Note how these terms are used together in the ADLs. For example, there is intermittent supervision and intermittent assistance.

CLARIFICATION OF ADL RESPONSES

19. EATING:

#3 "Requires continual help. . ." means that the patient requires a staff person's continual presence and help for reasons such as: patient tends to choke, has a swallowing problem, is learning to feed self, or is quite confused and forgets to eat.

#5 "Tube or parenteral feeding. . ." means that all food and drink is given by nursing staff through the means specified.

20. MOBILITY:

#3 "Walks with constant supervision and/or assistance. . ." may be required if the patient cannot maintain balance, has a history of falls, has stress fracture potential, or is relearning to ambulate.

21. TRANSFER: Exclude transfers to bath or toilet.

#4 "Requires two people. . ." may be required for reasons such as: the patient is obese, has contractures, has fractures (or stress fracture potential), has attached equipment that makes transfer difficult (for example, tubes). There must be a logical medical reason why the patient needs the help of two people to transfer.

#5 "Bedfast. . ." may refer to a patient with acute dehydration, severe decubitus, or terminal illness.

22. TOILETING:

Definition - INCONTINENT - 60 percent or more of the time the patient loses control of his/her bladder or bowel functions, with or without equipment.

#1 "Continent. . . . Requires no or intermittent supervision" and #2 ". . . and/or assistance" can refer to the continent patient or the incontinent patient who needs no/little help with his/her toileting equipment (for example, catheter).

#3 "Continent. . . Requires constant supervision/total assistance. . ." refers to a patient who may not be able to balance him/herself and transfer, has contractures, has a fracture, is confused or is on a rehabilitation program. In addition this level refers to the patient who needs constant help with elimination/incontinence appliances (for example, colostomy, ileostomy).

#4 "Incontinent. . . Does not use a bathroom" refers to the patient who does not go to a toilet room, but instead may use a bedpan or continence pads. This patient may be bed bound or mentally confused to the extent that a scheduled toileting program is not beneficial.

#5 "Incontinent. . . Taken to a Bathroom. . ." refers to a patient who is on a formal toileting schedule, as documented in the medical record. This patient may be on a formal bowel and bladder rehabilitation program to regain or maintain control, or the toileting pattern is known and it is better psychologically and physically for the patient to be taken to the toilet (for example, to prevent decubiti).

A patient may have different levels of toileting capacity for bowel and bladder function. To determine the level of such a patient, note that level four and five refer to incontinence of either bladder or bowel. Thus if a patient receives the type of care described in one of these levels for either type of incontinence, enter that level.

Example 1: A patient needs constant assistance with a catheter (level 3) and is incontinent of bowel and is taken to the bathroom every four hours (level 5). In this instance, enter level 5 on the PRI because he is receiving the type of care described in this question for bowel incontinence.

Example 2: The patient requires intermittent supervision for bowel function (level 2) and is taken to the toilet every two hours as part of a bladder rehabilitation program. Enter level 5, as the patient is receiving this type of care for bladder incontinence.

IV. BEHAVIORS - VERBAL DISRUPTION; PHYSICAL AGGRESSION; DISRUPTIVE, INFANTILE/SOCIALLY INAPPROPRIATE BEHAVIOR; AND HALLUCINATIONS

The following qualifiers must be met:

Time Period -	Past four weeks.
Frequency -	As stated in the responses to each behavioral question.
Documentation -	To qualify a patient as LEVEL 4 or to qualify the patient as a "YES" to HALLUCINATIONS, the following conditions must be met:
* Active treatment plan for the behavioral problem must be in current use.
* Psychiatric assessment by a recognized professional with psychiatric training/ education must exist to support the fact that the patient has a severe behavioral problem. The problem addressed by this assessment must still be exhibited by the patient.
Definitions -	The terms used on the PRI should be interpreted only as they are defined below:
* PATIENT'S BEHAVIOR: Measure it as displayed with the behavior modification and treatment plan in effect during the past four weeks.
* DISRUPTION: Through verbal outbursts and/or physical actions, the patient interferes with the staff and/or other patients. This interference causes the staff to stop or change what they are doing immediately to control the situation. Without this staff assistance, the disruption would persist or a problem would occur.
* NONDISRUPTION: Verbal outbursts and/or physical actions by the patient may be irritating, but do not create a need for immediate action by the staff.
* UNPREDICTABLE BEHAVIOR: The staff cannot predict when (that is, under what circumstances) the patient will exhibit the behavioral problem. There is no evident pattern.
* PREDICTABLE BEHAVIOR: Based on observations and experiences with the patient, the staff can discern when a patient will exhibit a behavioral problem and can plan appropriate responses in advance. The behavioral problem may occur during activities of daily living (for example, bathing), specific treatments (for example, contracture care, ambulation exercises), or when criticized, bumped into, etc.

CLARIFICATION OF RESPONSES TO BEHAVIORAL QUESTIONS

23. VERBAL DISRUPTION: Exclude verbal outbursts/expressions/utterances which do not create disruption as defined by the PRI.

24. PHYSICAL AGGRESSION: Note that the definition states "with intent for injury."

25. DISRUPTIVE, INFANTILE OR SOCIALLY INAPPROPRIATE BEHAVIOR: Note that the definition states this behavior is physical and creates disruption.

EXCLUDE the following behaviors:

* Verbal outbursts

* Social withdrawal

* Hoarding

* Paranoia

26. HALLUCINATIONS: For a "YES" response, the hallucinations must occur at least once per week during the past four weeks, in addition to meeting the other qualifiers noted above for an active treatment plan and psychiatric assessment.

V. SPECIALIZED SERVICES

27. PHYSICAL AND OCCUPATIONAL THERAPIES:

* For each therapy these three types of information will be entered on the PRI; "Level", "Days" and "Time" (hours and minutes).

* For a patient not receiving a therapy at all, the "Level" will always be entered in the answer key as #1 ("does not receive"), the "Days" will be entered 0 (zero) and the "Time" will be 0 (zero).

* Use the chart on this page to understand the qualifiers for each of the three types of information that will be entered. Whether a patient is receiving maintenance or restorative therapy will make a difference in terms of the qualifiers to be used.

SEE CHART THAT FOLLOWS FOR THE SPECIFIC QUALIFIERS.

27.^*LEVEL QUESTION:^**QUALIFIERS (see level 4 below)

QUALIFIERS FOR LEVEL	MAINTENANCE THERAPY = LEVEL 2	RESTORATIVE THERAPY = LEVEL 3
DOCUMENTATION QUALIFIERS: POTENTIAL FOR INCREASED FUNCTIONAL/ADL ABILITY	None. Therapy is provided to maintain and/or retard deterioration of current functional /ADL status. Therapy plan of care and progress notes should support that patient has no potential for further or any significant improvement.	There is positive potential for improved functional status within a short and predictable period of time. Therapy plan of care and progress notes should support that patient has this potential/ is improving.
PHYSICIAN ORDER, NURSE PRACTITIONER ORDER (IN CONFORMANCE WITH A WRITTEN PRACTICE AGREEMENT WITH A PHYSICIAN), OR APPROPRIATELY COSIGNED PHYSICIAN ASSISTANT ORDER	Yes	Yes, monthly
PROGRAM DESIGN AND EVALUATION QUALIFIER	Licensed professional person with a 4 year, specialized therapy degree evaluates program on a monthly basis.	Licensed professional person with a 4 year, specialized therapy degree evaluates program on a monthly basis.
TIME PERIOD QUALIFIER	Treatments have been provided during the past four weeks.	Treatments have been provided during the past four weeks.
NEW ADMISSION QUALIFIER	Not Applicable	New admissions of less than four weeks can be marked for restorative therapy if:
* There is a physician order, nurse practitioner order (in conformance with a written practice agreement with a physician), or appropriately cosigned physician assistant order for therapy and patient is receiving it.
* The licensed therapist has documented in the care/plan that therapy is needed for at least four weeks.
* A new admission includes readmission to a residential health care facility.

27. DAYS AND TIME PER WEEK QUESTION: QUALIFIERS^***

QUALIFIERS FOR DAYS AND TIME***	MAINTENANCE THERAPY (i.e., level 2 or 4 under "Level" question)	RESTORATIVE THERAPY (i.e., If level 3 or 4 under "Level" question)
TYPE OF THERAPY SESSION	Count only one-to-one care. Exclude group sessions (e.g., PT exercise session, OT cooking session).	Count only one-to-one care. Exclude group sessions (e.g., PT exercise session, OT cooking session).
SPECIALIZED PROFESSIONAL ON-SITE (ON- SITE MEANS WITHIN THE FACILITY)	A certified (2 year) or licensed (4 year) specialized professional is on-site supervising or providing therapy.	A licensed (4 year) specialized professional is on-site supervising or providing care. (Do not include care provided by PT or OT aides.)

28. NUMBER OF PHYSICIAN VISITS: Enter "0" (zero) unless the patient need qualifiers stated below are met. If, and ONLY if, the patient meets all the patient need qualifiers, then enter the number of physician visits, nurse practitioner visits (in conformance with a written practice agreement with a physician), or physician assistant visits that meet the physician, nurse practitioner, or physician assistant visit qualifiers.

* PATIENT TYPE/NEED QUALIFIERS: The patient has a medical condition that (1) is unstable and changing or (2) is stable, but there is high risk of instability. If this patient is not closely monitored and treated by medical staff, an acute episode or severe deterioration can result. Documentation must support that the patient is of this type (for example, terminally ill, acute episode, recent hospitalization, post-operative).

* PHYSICIAN, NURSE PRACTITIONER, OR PHYSICIAN ASSISTANT VISIT QUALIFIER: If, and only if, the patient meets the PATIENT TYPE/NEED QUALIFIER, then enter the number of physician visits, nurse practitioner visits (in conformance with a written practice agreement with a physician), or physician assistant visits during the past four weeks that meet the following qualifications:

* A visit qualifies only if there is physician, nurse practitioner, or physician assistant documentation that she/he has personally examined the patient to address the pertinent medical problem. The physician, nurse practitioner, or physician assistant must make a notation or documentation in the medical record as to the result of the visit for the unstable medical condition (e.g., change medications, renew treatment orders, nursing orders, order lab tests).

* Do not include phone calls as a visit nor visits which could have been accomplished over the phone.

* A visit qualifies whether it is on-site or off-site, as long as the patient is not an inpatient in a hospital/other facility.

29. MEDICATIONS

A. Monthly average number of all medications ordered: Enter the monthly average number of different medications for which physician orders were written over the course of the past six months. If the resident has been in the facility less than six months determine the monthly average number of medications ordered based on the number of months since admission. The average should include the total number of ordered medications whether or not they were administered: (PRN medications; injectables, ointments, creams, ophthalmics, short-term antibiotic regimens and over-the-counter medications, etc.)

B. Monthly average number of psychoactive medications ordered: Enter the monthly average number of psychoactive medications for which physician orders were written over the course of the past six months. If the resident has been in the facility less than six months, determine the monthly average of psychoactive medications ordered based on the number of months since admission. The average should include all ordered psychoactive medications whether or not they were actually administered.

A "psychoactive" medication is defined as a medication that is intended to affect mental and/or physical processes, namely to sedate, stimulate, or otherwise change mood, thinking or behavior.

The following are classes of psychoactive medications with several examples listed in each:

* Antidepressants - Amitriptyline (Elavil); Imipramine (Tofranil); Doxepin (Sinequan); Tranylcpromine (Parnate); Phenelzine (Nardil) .......

* Anticholinergics - Benztropine (Cogentin); Trihexyphenidyl (Artane) .......

* Antihistamines - Diphenhydramine (Benadryl); Hydroxyzine (Atarax) .......

* Anxiolytics - Chlordiazepoxide (Librium); Diazepam (Valium) .......

* Cerebral Stimulants - Methylphenidate (Ritalin); Amphetamines (Benzedrine) .......

* Neuroleptics - Phenothiazines; Thiothixene (Navane); Haloperidol (Haldol); Chlorpromezine (Thorazine); Thioridazine (Mellaril) .......

* Somnifacients - Barbituates (Nembutal); Temazepam (Restoril); Glutethimide (Doriden); Flurazepam (Dalmane) .......

VI. DIAGNOSIS

30. PRIMARY MEDICAL PROBLEM: Follow the guidelines stated below when answering this question.

* NURSING TIME: The primary medical problem should be selected based on the condition that has created the most need for nursing time during the past four weeks. A review of the medical record for nursing and physician, nurse practitioner, or physician assistant notes during the past four weeks may be necessary.

* JUDGMENT: This decision may require the assessor to use her/his own professional judgment in deciding upon the primary problem.

* ICD-9: Refer to the ICD-9 Codes for Common Diagnoses attached at the end of these instructions for easy access to the most frequently used numbers. An ICD-9 code book containing the complete ICD-9 listing should be available in the nursing and/or medical records office of a facility.

* NO ICD-9 NUMBER: Enter "0" (zero) in the far right box if no ICD-9 number can be found for the patient's primary problem (or if the patient does not have a primary medical problem). If you cannot locate the ICD-9 code for the primary medical problem, PRINT THE NAME OF THE PRIMARY MEDICAL PROBLEM in the space provided on the PRI.

* NOTE: If the patient has AIDS or HIV related illnesses, indicate this in Section II, Medical Events, Item 17F. Do not use AIDS or HIV specific ICD codes (042044). Instead, use the code of the specific problem requiring the most caregiver time. For example, for all patients for whom viral pneumonia (NOS) is the condition requiring the most caregiver time, enter 480.9. Do not enter 042.1 for patients with HIV infection.

31. QUALIFIED ASSESSOR NUMBER: The qualified assessor who is attesting to the accuracy of the assessment must sign the completed form and enter the assessor Identification Number which was assigned at an approved N.Y.S. Department of Health Training Program.

Since the PRI is completed and submitted for the purposes of a reimbursement assessment cycle, the certified assessor must have actually completed the patient assessment, utilizing medical records and/or observations or interviews of the patient. This should be indicated by checking the YES box.

38. RACE/ETHNIC GROUP:

The following definitions are to be utilized in determining race and ethnic groups:

1. WHITE: A person having origins in any of the original peoples of Europe, North Africa or the Middle East.

2. WHITE/HISPANIC: A person who meets the definition of both White and Hispanic (See Hispanic below).

3. BLACK: A person having origins in any of the Black racial groups of Africa.

4. BLACK/HISPANIC: A person who meets the definition of both Black and Hispanic (see below).

5. ASIAN or PACIFIC ISLANDER: A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This includes, for example, China, Japan, Korea, the Philippine Islands and Samoa.

6. ASIAN or PACIFIC ISLAND/HISPANIC: A person who meets the definition of both Asian or Pacific Islander and Hispanic (see below).

7. AMERICAN INDIAN or ALASKAN NATIVE: A person having origins in any of the original peoples of North America and who maintains tribal affiliation or community recognition.

8. AMERICAN INDIAN or ALASKAN NATIVE/HISPANIC: A person who meets the definition of both American Indian or Alaskan Native and Hispanic (see below).

9. OTHER: Other groups not included in previous categories.

HISPANIC: A person of Puerto Rican, Mexican, Cuban, Dominican, Central or South American, or other Spanish Culture or origins.

(j) Residential health care facilities shall submit the data contained in the PRI using an electronic medium, including but not limited to magnetic computer tape, floppy disk or an electronic telecommunication system consistent with the technical specifications established by the department.

(1) The electronically produced data shall be accompanied by a certification statement executed by the operator or a person authorized to sign on the operator's behalf in a format provided or approved by the department.

(2) Facilities shall have an additional 10 days from the time specified pursuant to subdivision (b) of this section to file the required information.

(3) Adjustments to certified rates made pursuant to section 86-2.11 of this Subpart shall be certified by the Commissioner of Health within 90 days from the date upon which a facility's rate was last certified pursuant to this Subpart, or within 90 days from the latest scheduled PRI submission date pursuant to section 86-2.11 of this Subpart, whichever is later. Such 90-day time frames shall not apply in any instance where a facility has been notified that its submitted PRI data is inaccurate or incorrect pursuant to paragraph (e)(4) of this section until such data has been corrected to the satisfaction of the commissioner, or if an additional onsite review has been deemed necessary pursuant to paragraph (e)(5) of this section.

Footnotes

* After completion of the "Level" question, proceed to the separate "Days" and "Time" qualifiers on the next page.

** QUALIFIERS NOT MET = LEVEL 4: ENTER LEVEL 4 IF ANY ONE OF THE QUALIFIERS UNDER QUALIFIERS FOR LEVELS 2 OR 3 IS NOT MET.

*** QUALIFIERS NOT MET: DO NOT ENTER ON THE PRI ANY DAYS AND TIME OF THERAPY WHICH DO NOT MEET BOTH THE QUALIFIERS UNDER EACH LEVEL OF THERAPY.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-2.30