New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter A - Medical Facilities-minimum Standards › Article 1 - General › Part 400 - All Facilities-General Requirements › Section 400.13 - Forms (Hospital/Community Patient Review Instrument)

Current through Register Vol. 46, No. 28, July 10, 2024
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NEW YORK STATE DEPARTMENT OF HEALTH
DIVISION OF HEALTH CARE FINANCING
INSTRUCTIONS: HOSPITAL AND COMMUNITY
						PATIENT
REVIEW INSTRUMENT (H/C-PRI)
GENERAL CONCEPTS
1.
PURPOSE:
Preadmission review
					 to a Residential Health Care Facility (RHCF) from the hospital and community
					 based residences and facilities, such as personal dwelling, domicillary care
					 facility/adult home and congregate housing.
2.
ASSESSORS:
As qualified
					 through the N.Y.S. Department of Health PRI Training Program - hospital
					 discharge planners, certified home health care agency registered nurses, RHCF
					 registered nurses, county public health nurses and other utilization review
					 personnel as designated.
3.
USING THESE INSTRUCTIONS:
These instructions should be read before
					 completing the H/C-PRI and should be kept with the H/C-PRIs as they are being
					 completed.
FREQUENT REFERENCE TO THE INSTRUCTIONS WILL BE NEEDED TO
					 COMPLETE THE H/C-PRI ACCURATELY.
4.
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:
					 //
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.
5.
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 week. For the patients who have been in the hospital less
						than one week use the time from admission to H/C-PRI completion as the
						timeframe. If the community assessor (e.g., certified home health care agency,
						RHCF assessor) does not have any history on the patient, then the day of the
						H/C-PRI assessment is the timeframe. See "Sources of Information" below.
*
FREQUENCY
- The frequency specifies how
						often something needs to occur to meet the qualifier. For example, suctioning
						needs to occur daily for at least one week 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 oxygen therapy.
6.
SOURCES OF
					 INFORMATION:
For community based referred patients, the sources of
					 information may not be as accessible as in the hospital. Discussion with the
					 patient's family members, other caregivers and personal physician(s) will help
					 provide more accurate information. The patient may be recieving community
					 services or may have in the past.
7.
ACTIVITIES OF DAILY LIVING
					 (ADLs):
The approach to measuring ADLs is slightly different from other
					 PRI questions. Measure how capable the patient is in completing each ADL 60% or
					 more of the time it needs to be performed.
CAPABILITY
- Reviewing
					 the patient's physical and mental status, measure the present capability of the
					 patient to perform each ADL. This is in contrast to how the patient may be
					 actually performing the ADLs in the hospital/facility or in the community. Read
					 the specific instructions on ADLs to understand the
CHANGED CONDITION
					 RULE,
the specific ADL definitions and the measurement of
					 capability.
8.
CORRECTIONS:
Cross out any responses which you wish to change and
					 reenter clearly to the right of the original response. Example: /3/4
INSTRUCTIONS: H/C-PRI QUESTIONS
I.
ADMINISTRATIVE DATA
1.
OPERATING CERTIFICATE NUMBER:
Enter the seven or eight character identifier stated on the facility's/agency's
					 operating certificate. For a hospital there will always be seven (7) numbers
					 followed by an "H" in the eighth box. For a certified home health agency and a
					 county Department of Health, there will only be seven (7) numbers with no
					 letters. This means the first answer box to the left will remain blank. For a
					 residential health care facility, there will be seven (7) numbers followed by
					 an "N" which indicates a nursing facility.
2.
SOCIAL SECURITY NUMBER:
Do
					 not leave blank; enter zero in far right hand box if patient does not have a
					 number.
3.
OFFICIAL FACILITY
					 NAME:
Print the formal name of the hospital/community agency,
					 etc.
4.
PATIENT NAME:
When completing the H/C-PRI do not use nicknames. Print last name first (e.g.,
					 Brant, Diana C).
6.
MEDICAL
					 RECORD NUMBER/CASE NUMBER:
Enter the unique number assigned by the
					 hospital/agency to identify each patient. It is not the Medicaid, Medicare or
					 Social Security number, unless that is the number used to identify patients. If
					 there is no assigned case number for the community based patient, leave this
					 question blank.
7.
HOSPITAL
					 ROOM NUMBER:
Enter the numbers and/or letters which identify the
					 patient's room in the hospital or other applicable community facility. If the
					 patient is residing in the community when the H/C-PRI review is completed, then
					 print the address in question 4., "Patient Name." (Community is defined as a
					 personal dwelling, Adult Home, congregate housing, or other domicillary type
					 facilities/dwellings.)
8.
NAME OF HOSPITAL UNIT/BUILDING/DIVISION:
Print the name of the
					 hospital unit, such as "med-surgery," where the patient was reviewed. Include
					 any other unique hospital location identifiers, such as specific building names
					 where the unit is located. However, if the patient has changed units or
					 buildings or will be moving, then print instead where the patient can be
					 located in the future (if known). If the patient is reviewed in the community,
					 then this question is not applicable and can be left blank.
11A.
DATE OF HOSPITAL ADMISSION OR
					 INITIAL AGENCY VISIT:
Enter in numerical format the month, day and year
					 the patient was admitted to this hospital for the purposes of this review. (Use
					 most recent hospitalization date for multiple hospitalizations.) Do not include
					 the date of Alternate Level of Care status (ALC), rather enter this date, if
					 applicable, in Question 11B. If the patient is being reviewed in the community,
					 enter the date of the initial patient visit by the certified home health care
					 agency, nursing home or any other qualified agency/organization. This visit may
					 be a followup to a referral made by the patient, the patient's family, the
					 patient's physician, etc.
11B.
DATE OF ALTERNATE LEVEL OF CARE STATUS:
Enter in numerical format
					 the day, month and year the patient went onto Alternate Level of Care status
					 (ALC) in the hospital. If the patient has entered ALC status more than once
					 during this hospital stay, enter the most recent ALC admission date. (That is,
					 this patient was on ALC status, but was discharged because of an acute episode
					 and then went back to ALC status.) If the patient is not on ALC status or is in
					 the community during this review, enter a zero (0) in far right hand
					 box.
12.
MEDICAID
					 NUMBER:
Enter these numbers if patient has such coverage.
13.
MEDICARE NUMBER:
available,
					 whether or not the coverage is being used. If not, enter only one zero in the
					 far right hand box.
14.
PRIMARY PAYOR:
Enter the one source of coverage which pays for
					 most of the patient's current hospitalized stay; for patients in the community
					 enter what is covering the patient's community health care needs. Code "other"
					 only if the primary payor is not Medicaid or Medicare. "Other" includes
					 self-pay and private insurance.
15.
REASON FOR PRI COMPLETION:
Select the one reason why the PRI is
					 being completed. This is for preadmission review purposes.
# 1 RHCF Application from Hospital means the patient
						resides in the hospital at the time of this H/C-PRI review and is applying for
						admission into a residential health care facility (RHCF, HRF or SNF). This
						H/C-PRI is being completed by a qualified hospital assessor or another
						qualified assessor (i.e., RHCF assessor, certified home health care agency
						assessor) who enters the hospital to review the patient.
# 2 RHCF Application for Community means the patient
						resides in the community during this H/C-PRI review. Include Adult Homes and
						other domicillary care facilities.