Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Appendix M - DEPARTMENTAL DETERMINATIONS

Current through Register Vol. 54, No. 28, July 13, 2024
The Department is required to determine the need for
						nursing care and active treatment for all applicants to nursing homes who are
						mentally ill, mentally retarded or who have a related condition unless
						otherwise exempt.
For Departmental Determination of the applicant's need
						for nursing care and active treatment, the following information must be sent
						with the LAMP Summary and the PASARR-EV to the appropriate office listed in
						Appendix G. If a new evaluation or set of evaluations are required, those
						preparing their reports should address themselves to the following
						items.
I.
Determination of All Persons
. Data
						sent to the Department for determination of need for nursing care for all
						persons must include:
A. The finding that the applicant's medical needs cannot
						be adequately met in noninstitutional settings include at least:
1. An evaluation of medical status including at least the
						applicant's:
a. Diagnoses.
b. Date of onset.
c. Medical history.
d. Prognosis.
2. A history of previous rehabilitation within the past
						year.
B. A recommendation based upon medical determination that
						nursing care is needed.
II.
Determination of Persons with Mental
						Illness
. Data sent to the Department for determinations to be made for
						persons with mental illness must also include a recommendation and sufficient
						supporting information in order to determine whether or not the person needs
						the implementation of "active treatment" in order to be able to function.
						Information must include:
A. A comprehensive history and physical examination of
						the person. At a minimum, the examination must address the following areas-if
						not previously addressed:
1. Complete medical history.
2. Review of all body systems.
3. Specific evaluation of the person's neurological
						system in the areas of:
a. Motor functioning.
b. Sensory functioning.
c. Gait.
d. Deep tendon reflexes.
e. Cranial nerves.
f. Abnormal reflexes.
4. In case of abnormal findings which are the basis for a
						nursing facility placement, additional evaluations must be conducted by
						appropriate specialists.
5. If the history and physical examination used for the
						PASARR Determination is not performed by a physician, then a physician's
						countersignature is required.
B. A comprehensive drug history of all current or
						immediate past utilization of medications used by the person that could mask
						symptoms, as well as the use of medications that could mimic mental
						illness.
C. A psychosocial evaluation of the person. At a minimum,
						this includes an evaluation of the following:
1. Current living arrangements.
2. Medical and support systems.
3. If the psychosocial evaluation is not conducted by a
						social worker, then a social worker's countersignature is required.
D. A comprehensive mental health evaluation. At a
						minimum, the evaluation must address the following areas:
1. Complete mental health history.
2. Evaluation of intellectual functioning, memory
						functioning, and orientation.
3. Description of current attitudes and overt
						behaviors.
4. Affect.
5. Suicidal/homicidal ideation.
6. Degree of reality testing-presence and content of
						delusions-and hallucinations.
7. If the mental health evaluation is not performed by a
						physician who is knowledgeable about mental illness or a clinical psychologist.
						Then the countersignature of one or the other is required.
E. The information must include all medical and
						psychiatric diagnoses which require treatment. Copies of previous discharge
						summaries-during the past 2 years.
III.
Determination of Persons with Mental
						Retardation or Related Conditions
. Data sent to the Department for
						determination to be made for persons with mental retardation or other related
						conditions must also include a recommendation and sufficient supporting
						information to determine whether or not the person needs the implementation of
						a continuous "active treatment" program as defined at
						42 CFR
						435.1009"Active Treatment in Intermediate
						Care Facilities for the Mentally Retarded" in order to be able to function.
						Information must include:
A. The individual's comprehensive history and physical
						examination results so that the following, minimum information can be
						identified:
1. A list of the individual's medical problems.
2. The level of impact these problems have on the
						individual's independent functioning.
3. A list of all current medications used by the
						individual.
4. Current response of the individual to any prescribed
						medications in the following drug groups:
a. Hypnotics.
b. Antipsychotics (neuroleptics).
c. Mood stabilizers and antidepressants.
d. Antianxiety-sedative agents.
e. Anti-parkinsonian agents.
B. An assessment of the individual's:
1. Self-monitoring of health status.
2. Self-administering and/or scheduling of medical
						treatments.
3. Self-monitoring of nutrition status.
4. Self-help development-such as: toileting, dressing,
						grooming and eating.
5. Sensorimotor development-such as: ambulation,
						positioning, transfer skills, gross motor dexterity, visual motor/perception,
						fine motor dexterity, eye-hand coordination and extent to which prosthetic,
						orthotic, corrective or mechanical supportive devices can improve the
						individual's functioning capacity.
6. Speech and language (communication) development-such
						as: expressive language (verbal and nonverbal), receptive language (verbal and
						nonverbal), extent to which nonoral communication systems can improve the
						individual's functional capacity, auditory functioning and extent to which
						amplification devices (hearing aid) or a program amplification can improve the
						individual's functional capacity.
7. Social development, such as: interpersonal skills,
						recreation-leisure skills and relationships with others.
8. Academic/educational development, including functional
						learning skills.
9. Independent living development-such as: meal
						preparation, budgeting and personal finances, survival skills, mobility skills
						(orientation to the neighborhood, town, city), laundry, housekeeping, shopping,
						bedmaking, care of clothing, and orientation skills-for individuals with visual
						impairments.
10. Vocational development, including present vocational
						skills.
11. Affective development-such as: interests and skills
						involved with expressing emotions, making judgements and making independent
						decisions.
12. Presence of identifiable maladaptive or inappropriate
						behaviors of the individual based on systematic observation-including, but not
						limited to, the frequency and intensity of identified maladaptive or
						inappropriate behaviors.
C. The information conveyed to the Department must
						identify to what extent the person's status compares with each of the following
						characteristics, commonly associated with need for active treatment:
1. Inability to take care of most personal care
						needs.
2. Inability to understand simple commands.
3. Inability to communicate basic needs and wants.
4. Inability to be employed at a productive wage level
						without systematic long term supervision or support.
5. Inability to learn new skills without aggressive and
						consistent training.
6. Inability to apply skills learned in a training
						situation to other environments or settings without aggressive and consistent
						training.
7. Without direct supervision, inability to demonstrate
						behavior appropriate to the time, situation or place.
8. Demonstration of severe maladaptive behaviors which
						place the person or others in jeopardy to health and safety.
9. Inability or extreme difficulty in making decisions
						requiring informed consent.
10. Presence of other skill deficits or specialized
						training needs which necessitates the availability of trained Mental
						Retardation personnel, 24 hours per day, to teach the person to learn
						functional skills.
D. The information must indicate that a psychologist, who
						meets the qualifications of a Qualified Mental Retardation Professional, as
						defined in 42 CFR
						483.430(a)(1)(2):
1. Identifies the individual's intellectual functioning
						measurement.
2. Validates the individual has mental retardation or a
						related condition.
3. Recommends whether the individual needs active
						treatment to function.
This appendix cited in 55 Pa. Code §
													1181.544 (relating to where and
						  how evaluations will be made); and 55 Pa. Code §
													1181.546 (relating to how
						  providers and applicants will be notified).