Ohio Administrative Code › Title 5122 - Department of Mental Health and Addiction Services › Chapter 5122-21 - Preadmission Screening and Annual Review › Section 5122-21-03 - Pre-admission screening and resident review (PASRR) for nursing facility applicants and residents with serious mental illness

Current through all regulations passed and filed through July 1, 2024
(A) Purpose:
This rule sets forth a process for a state-contracted vendor
				and the Ohio department of mental health and addiction services to respectively
				evaluate and determine whether an individual with indications of serious mental
				illness (SMI) requires those services provided in a medicaid-certified nursing
				facility (NF), and if so whether that individual needs specialized services for
				mental illness that exceed NF services.
(B) Applicability:
This rule applies to individuals who have indications of SMI
				and are seeking admission into a NF, and for NF residents with indications of
				SMI who are seeking to continue residing in a NF. It also applies to
				individuals seeking readmission to a NF after having transferred from a NF to a
				hospital or unit that is licensed or certified by the department, and to
				individuals with indications of SMI who are transferring from one NF to another
				NF, with or without an intervening hospital stay.
(C) Definitions:
(1) An "administrative letter' is a
			 communication device in which the state declines to reconsider a previously
			 issued PASRR determination to the individual or guardian. An administrative
			 letter is not a new PASRR determination, thus it does not carry appeal
			 rights.
(2) "Adverse determination'
			 means a determination made in accordance with rules
			 5160-3-15,
			 5160-3-15.1, 5160-3- 15.2, 5122-21-03 and 5123-14-01 of the Administrative
			 Code, that an individual does not require the level of services provided by a
			 NF. This includes any PASRR determination issued by the department that allows
			 a time-limited approval, such as a categorical, time specified, or an
			 extension.
(3) "Assessor' means a
			 professional possessing a clinical licensure approved by the department's
			 medical director to complete the level II PASRR evaluation.
(4) "Attending Physician' means the physician
			 whom an individual, or the family of an individual, has assigned primary
			 responsibility for the treatment of care of the individual, or if the
			 individual or the individual's family has not assigned responsibility, the
			 physician who has accepted responsibility.
(5) "Business day' means a day of the week,
			 excluding Saturday, Sunday, or a legal holiday as defined in section
			 1.14 of the Revised
			 Code.
(6) "Board of alcohol, drug
			 addiction, and mental health services" or "board" means the body constituted
			 according to section 340.02 of the Revised Code, or a
			 community mental health board or an alcohol and drug addiction services board
			 as described in section
			 340.021 of the Revised Code;
			 which have the same duties as described in section
			 340.03 of the Revised
			 Code,
(7) "Categorical
			 determination' means a presumptive pre-admission screen (PAS) approval issued
			 without the completion of a face to face assessment for an individual diagnosed
			 with developmental disabilities (DD) or SMI.
(8) "Department' means the Ohio department of
			 mental health and addiction services.
(9) "Developmental disability' (DD) has the
			 same meaning defined in rule
			 5123-14-01
			 of the Administrative Code.
(10)
			 "DODD' means the Ohio department of developmental disabilities.
(11) "Evaluation' also known as an assessment
			 or a level II evaluation as defined in rule
			 5160-3-15
			 of the Administrative Code, includes a face to face interview between an
			 assessor and the individual, their guardian, or authorized representative, if
			 applicable. The purpose of an evaluation is to assess the individual's need for
			 the level of services provided in a NF, and to assess whether the individual
			 would need specialized services for mental illness if approved for NF
			 services.
(12) "Extension' is a
			 time-limited approval for up to ninety days of additional stay in a NF,
			 following a previously issued specified-period or extension approval, granted
			 in accordance with rule 5160-3-15.2 of the Administrative Code. An extension is
			 given solely to allow for effective discharge planning.
(13) "Guardian' has the same meaning as in
			 section 2111.01 of Revised
			 Code.
(14) "Hospital exemption'
			 (exempted hospital discharge) means the same as defined in rule
			 5160-3-15
			 of the Administrative Code.
(15)
			 'Indefinite approval is an approval that permits a NF to admit an individual
			 diagnosed with SMI. Individuals admitted to a NF under an indefinite approval
			 will be required to adhere to all PASRR requirements related to NF
			 residents.
(16) "Individual' in
			 this rule means a person regardless of payment source, who is seeking
			 admission, readmission, or transfer to a medicaid-certified NF or a facility in
			 the process of becoming medicaid-certified NF.
(17) "Level I' means the same as defined in
			 rule
			 5160-3-15
			 of the Administrative Code.
(18)
			 "Level II' means the combination of the disability-specific PASRR evaluation
			 and the determination issued by DODD and/or the department.
(19) "Level II determination' or
			 "determination" in this rule means the department's finding of whether an
			 individual diagnosed with SMI requires the level of services provided in a NF,
			 and whether the individual requires specialized services for mental illness if
			 found to require NF services.
(20)
			 "Long-term resident' means the same as defined in rule
			 5160-3-15
			 of the Administrative Code.
(21)
			 "Nursing facility' (NF) has the same meaning as in section
			 5111.20 of Revised Code. A
			 long-term care facility that has submitted an application packet for medicaid
			 certification to the Ohio department of medicaid (ODM) is considered to be in
			 the process of obtaining its initial medicaid certification by the Ohio
			 department of health (ODH) and shall be treated as NF for purposes of this
			 rule.
(22) "Pre-admission
			 screening' refers to the level I screening as defined in paragraph (B)(15) of
			 rule
			 5160-3-15
			 of the Administrative Code.
(23)
			 "Psychiatric unit or hospital' refers to those facilities that are licensed or
			 operated by the department.
(24)
			 "Reviewer' refers to a licensed mental health clinician who reviews the PASRR
			 screen, supporting documents, the level II assessment, and the summary report
			 to issue the state's determination of whether the individual requires NF
			 services. If the determination is yes, then the reviewer indicates whether the
			 individual needs specialized services for mental illness. If it is determined
			 that the individual is not in need of NF services, then the reviewer may
			 recommend community service that may address the individual's needs.
(25) "Rule-out' means a determination made by
			 the department that the individual is not subject to further review. An
			 individual may be ruled-out at any time during the PASRR assessment when it is
			 determined that the individual:
(a) Does not
			 have SMI, even though the individual was diagnosed with mental
			 illness.
(b) Has a primary
			 diagnosis of dementia (including Alzheimer's disease or a related
			 disorder);
(c) Has a non-primary
			 diagnosis of dementia without a primary diagnosis that is a SMI; or,
(d) The individual has physician-ordered
			 end-of-life services.
(26) "Serious mental illness' (SMI) includes
			 the following criteria regarding diagnosis, level of impairment and recent
			 treatment:
(a) Diagnosis - The individual does
			 not have dementia for which the treatment is considered primary, but has a
			 major mental disorder diagnosable under the most recent edition of the
			 "Diagnostic and Statistical Manual of Mental Disorders" (DSM); and this mental
			 disorder includes, but is not limited to, one of the following: schizophrenia,
			 mood, delusional (paranoid), panic or other severe anxiety disorder, somatic
			 symptom disorder, personality disorder, other psychotic disorder, or a mental
			 disorder other than developmental disability that may lead to a chronic
			 disability diagnosable under the DSM.
(b) Level of impairment - within the past six
			 months, due to the mental disorder, the individual has experienced functional
			 limitations on a continuing or intermittent basis in major life activities that
			 would be appropriate for the individual's developmental stage.
(c) Recent treatment - the treatment history
			 indicates that the individual has experienced at least one of the following:
(i) Psychiatric treatment more intensive than
			 counseling and/or psychotherapy performed on an outpatient basis more than once
			 within the past two years.
(ii)
			 Within the last two years, due to the mental disorder, experienced an episode
			 of significant disruption to the usual living arrangement, for which supportive
			 services were required, or which resulted in intervention by housing or law
			 enforcement officials; or
(iii) Is
			 admitted to a psychiatric unit at the time of seeking NF services.
(27) "Significant change
			 in condition' means the same as is defined in rule 5160-03-15 of the
			 Administrative Code.
(28)
			 "Specialized services for mental illness' mean those services specified by the
			 PASRR determination for an individual diagnosed with SMI, which are arranged by
			 the department and may be provided under the behavioral health services as
			 described in rules
			 5160-8-05
			 and
			 5160-27-02
			 of the Administrative Code, which combined with services by the nursing
			 facility, results in the continuous and aggressive implementation of an
			 individualized plan of care in accordance with
			 42 C.F.R.
			 483.120, as in effect January 1,
			 2019.
(29) "Specified
			 determinations' is a time-limited approval that may be issued to a NF resident
			 for a stay of up to one hundred eighty days, for the completion of prescribed
			 therapies for which a NF is certified to provide, or to allow for effective
			 discharge planning.