Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter II - Specific Policies By Service › Section 144-101-II-67 - Nursing Facility Services › Subsection 144-101-II-67.05 - POLICIES AND PROCEDURES

Current through 2024-29, July 17, 2024
All nursing facilities must establish and maintain
						policies and practices regarding transfer, discharge, and the provision of
						services that are the same for all individuals regardless of source of
						payment.
67.05-1
Preadmission
					 Screening (PAS) and Change In Condition (CIC) Reviews for Mental Illness and
					 Intellectual Disability
A. Nursing
					 facilities must not admit any new resident who has: Mental Illness (MI), unless
					 the State mental health authority, has determined, based on an independent
					 evaluation performed by a person or entity other than the Department, prior to
					 admission, that the individual requires the level of services provided by a NF
					 and, if so, whether the individual requires specialized services for MI; or
					 Intellectually Disabled (ID) or other related conditions (ORC), unless the
					 State intellectual disability authority has determined prior to admission that
					 the individual requires the level of services provided by a NF, and, if so,
					 whether the individual requires specialized services for ID or ORC.
					 Determinations made by the State mental health or intellectual disability
					 authorities (Office of Adult Mental Health Services and Office of Adults with
					 Cognitive and Physical Disability Services) cannot be countermanded by the
					 State Medicaid agency (Maine Care Services) per
					 42 CFR
					 483.108, with the exception of appeal
					 determinations made through the system specified in subpart E of
					 42 CFR
					 483.204. The mental health and intellectual
					 disability authorities and the State Medicaid Agency are part of the Department
					 of Health and Human Services.
B.
					 NF's may not admit any individual who has not had preadmission screening for
					 mental illness, intellectual disability, or other related condition. All
					 applicants to a NF, regardless of payment source (private pay, Medicare,
					 MaineCare or other third-party payor) must be screened with the Level I screen:
1. Preadmission screening is not required in
					 the case of the readmission to a NF of an individual who, after being admitted
					 to the NF, was transferred for care in a hospital. However, such readmissions
					 are subject to a change in condition (CIC) review when indicated.
2. A Level II screen is not required for an
					 individual admitted to a NF directly from a hospital (after receiving acute
					 inpatient care) if the individual requires NF services for the condition for
					 which care was received in the hospital, and the attending physician certifies,
					 before admission to the NF, that the individual is likely to require a NF stay
					 of less than thirty (30) days.
If an individual who enters a NF as an exempted hospital
						discharge is later found to require more than thirty (30) days of NF care, a
						Level II assessment must be conducted if indicated within forty (40) calendar
						days of admission.
3. A
					 Level II screen may be deferred or waived, as appropriate, for an individual
					 who is likely to require a NF stay of less than thirty (30) days, and if the
					 individual qualifies for an advance categorical determination, as determined by
					 the State Mental Health Authority.
If an individual who enters a NF as an advance
						categorical determination and is later found to require more than thirty (30)
						days of NF care, a Level II assessment must be conducted, if indicated, within
						forty (40) calendar days of admission.
4. Interfacility transfers are subject to
					 change in condition (CIC) review when indicated. An interfacility transfer
					 occurs when an individual is transferred from one NF to another NF, with or
					 without an intervening hospital stay. In cases of transfer of a resident with
					 MI, ID or ORC from a NF to a hospital or another NF, the transferring NF is
					 responsible for ensuring that all PAS CIC records and resident assessment
					 reports accompany the transferring resident.
C. For each resident who has mental illness,
					 intellectual disability, or other related condition, a change in condition
					 (CIC) review must be conducted promptly after a significant change in physical
					 or mental condition occurs, in order to determine whether the resident requires
					 the level of services provided by a NF and, if so, whether the individual
					 requires specialized services for MI, ID, or ORC.
D. The Level I and Level II screening
					 procedures and time frames are described in the Manual issued by the mental
					 health and intellectual disability authorities. This Manual can be accessed on
					 line at:
http://www.maine.gov/dhhs/mh/PASRR/Contents.htm
Any NF applicant known or suspected to have a serious
						mental illness, as identified by the Level I screen, shall be referred to the
						mental health authority for a Level II assessment. The applicant shall be
						notified in writing that the need for specialized services will be determined
						through a Level II assessment.
Any NF applicant known or suspected to have an
						intellectual disability or a related condition, shall be notified in writing
						and referred to the nearest intellectual disability authority Regional Office
						for a Level II assessment.
The findings of a Level II assessment shall be submitted
						to the State Medicaid Agency within six (6) to eight (8) working days of the
						referral.
E. An applicant
					 or resident has the right to appeal the finding of need for specialized
					 services. He/she may request a hearing by submitting a verbal or written
					 request within ten (10) days of receipt of the notification letter or of the
					 final determination decision by writing to the Director, MaineCare Services,
					 #11 State House Station, Augusta, ME 04333-0011.
F. A NF or an entity that has a direct or
					 indirect affiliation or relationship with a NF, may not conduct PAS CIC
					 activities, with the exception of a Level I screen.
G. MaineCare will not cover NF services for
					 any individual found not to require NF services, with the following exception:
Any long term resident who has continuously resided in a
						NF for at least thirty (30) months before the date of determination, and who
						requires only specialized services for MI or ID, will be offered the choice of
						remaining in the NF or of receiving services in an alternate appropriate
						setting.
H. MaineCare will
					 only reimburse for services furnished after preadmission screening for MI, ID,
					 or ORC has been completed.
I.
					 Failure to implement preadmission screening, in accordance with established
					 procedures, for all NF applicants, regardless of payment source (e.g.:
					 MaineCare, Medicare, private pay, or other third-party payor), shall result in
					 sanctions from MaineCare Services.