Colorado Pre-Admission Screening and Resident Review

1. Colorado Pre-Admission Screening and Resident Review Level I PAS and RR Training June 2014

2. Multiple forms • Multiple Interpretations • Multiple places to document • Multiple and confusing dates • Colorado PASRR Level I and Resident Review Simplification

3. What simplification? • Has something changed? • What changes were made? • Why were these changes made? • When are these changes effective? • How will these changes impact me? • Colorado PASRR Simplification

4. What to expect today PASRR purpose Level I (Pre-Admission Screen) Level I Post-Admission update Resident Review/Status Change Diagnosis AND Triggers Surveys Questions Answered Session Discussions

5. Background • PASRR - Social Security Laws The preadmission screening and residents review program erected from the OmbnibusReconcialtion Act of 1987 (OBRA) under the Social Security Act as the governing rule for PASRR. The program was designed to address housing MI/DD in NF • PASRR - CMS (Centers for Medicare and Medicaid Services) Today the national PASRR program is managed under authority of the Centers for Medicare and Medicaid. OIG has criticized CMS for failing to monitor PASRR. States that participate with Medicaid must operate the federal PASRR program as a requirement of their state plan. • PASRR purpose

6. PASRR purpose PASRR WHAT YOU MIGHT NOT KNOW PASRR Operations Team PASRR Technical Assistance Center OIG Department of Justice Association of PASRR professionals PASRR and the Olmstead connection PASRR/MDS coordination (October 2013)

7. Operations (State Medicaid Agency) – HCPF Legal Responsibility to operate a PASRR program Financial Responsibility • Reporting • Tracking • Level II Evaluation and Determination Authority Mental Illness (State Mental Health Authority) DHS:DBH Intellectual Disability (State Intellectual Disability Authority) HCPF PASRR final approval for NF care and service determinations Determinations made by Level II authorities cannot be countermanded by SMA • PASRR purpose • operations & state agencies

8. State PASRR program operations must meet all CMS requirements • LEVEL I EVALUATION -completed online by referral source • State Medicaid Agency is responsible for Level I identification process • LEVEL II EVALAUTION -completed by Level II evaluators • State Mental Health Authority SMHA and State Intellectual Disability Authority SIDA • RESIDENT REVIEW – completed by appropriate OBRA/SIDA • PASRR purpose • operations by state authority

9. FORM SIMPLIFICATION PROJECT • PASRR contractor 2012 • Merge 3 Level I forms into 1 • Level I form online (December 2013) • Create a Post Level I to reflect current and accurate PASRR • Merge existing Status Change and Depression Diversions (PASRR operations team 2012/2013) • Create a Resident Review reflect current and accurate PASRR • Post Dear Administrator Letter (spring 2014) • So What Changes were made?

10. PASRR Level I – State Medicaid Agency: SMA • Must identify all individuals suspected of having MI or ID. “TRIGGER” • If Level I ‘tool’ is inadequate the state might be in violation of its obligation. • Objective to identify all possible triggers of PASRR • PASRR Level I Source: PASRR Technical Assistance Center

11. PASRR test positive = TRIGGER • Colorado PASRR refers to “positive” as a TRIGGER • A TRIGGER results in clinical review, with few exceptions • PASRR 1.5 (Clinical Review) • Whenever an individual has a positive TRIGGER, a state reviewer/clinician evaluates the record to determine if there is or is not a PASRR condition Yes_ refer for Level II or apply categorical/exclusions No_ may admit with or without conditions • PASRR Level I

12. PASRR Level I approved outcomes (final) • Non-Cert = screened and has no suspicion of MI/ID • Approved no MI/ID = positive trigger was reviewed and determined to have no suspicion of MI/ID • Approved ‘time limited’ = has triggers, can admit, meeting certain time limited criteria and must be reassessed for suspicion of PASRR if individual remains in NF post time limited approval. • Refer for Level II = Full Level II evaluation and determination required prior to admitting to facility or upon status change • PASRR Level I

13. PASRR Level I other outcomes (Not Final) • Hold For Review = Held for clinical review (1.5) Held for more information • Non-Cert Due to inconsistent information Narrative that does not match checked indicators • PASRR Level I

14. Intended to maintain currentand accurate PASRR • ONE TWO-SIDED paper document • New form current and accurate Level I update by 10/01/14 • Update as necessary for change of status (within 14 days) • Retained in the resident medical record • Usually precedes Resident Review/Status Change if warranted Reason for update and OBRA questions must be answered • Must be signed and dated by NF staff • PASRR Level I • Post Admission Level I update

15. Resident Demographics • New Diagnosis Includes anxiety, panic disorder, somatoform, personality disorders not previously screened • New Discovery of Intellectual Disability • Psychotropic medications given on a regular basis • New or worsened symptoms • Reason for update • Has OBRA has been contacted • PASRR Level I • Post Admission Level I update

16. Reason for Updated Level I is required and helps to identify the need to contact your OBRA coordinator. • Reasons that do not indicate to contact OBRA • Admitted without required PAS • Incorrect PAS (nursing facility change medication change) • Reasons to contact OBRA • New or worsened Serious Symptom • New Diagnosis as indicated by section I • Psychiatric meds for dementia not on or over the Beers List • New category of psychiatric medication started • Expiration of time limited approval • PASRR Level I post admission

17. PASRR Level I post admission

18. PASRR Level I post admission • VI. Reason for Updated Level I • Admitted without required PAS • Incorrect or missing PAS • New or worsened Serious Symptoms • New diagnosis identified in Section I. • Psychiatric meds for Dementia not on or over the Beer’s list • New category of psychiatric meds started for non-organic condition • Expiration of time limited approval Section VI Reason for update must be answered Tip • Nursing Facilities must contact OBRA for • Any Selections that apply EXCEPT: • Incorrect or missing PAS Admitted without PAS

19. PASRR Level I post admission Nursing Facility must indicate if the OBRA coordinator has been contacted as a result of this PASRR review Nursing Facility staff signature indicates PASRR review complete

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21. PASRR Level II –State Mental Health Authority • PASRR Level II –State Intellectual Disability Authority • Resident Review ensures individuals’ needs are met • SMHA/SIDA retain authority over criteria used in evaluating Resident Review • OBRAs conduct a 1.5 review to determine PASRR condition • SMA oversight ensures operations are compliant • Best Practice produces false positives • PASRR Resident Review • (Status Change) Source: PASRR Technical Assistance Center

22. Intent of NEW Resident Review/Status Change • Integrates previous Status Change Review and Depression Diversion forms • Stronger identification of PASRR triggers • Clearly identifies date of compliance • Incorporates all federally required diagnoses • Triggers more closely align with those identified on the Level I update • PASRR Resident Review • (Status Change)

23. Providing Information to the OBRA • OBRA coordinator determines method for information sharing (phone, fax, secure email) • OBRA coordinator determines what information is necessary to conduct a Resident Review/Status Change • Once OBRA coordinator has all the information they required from the SNF; OBRA coordinator has 3 business to complete the review. • PASRR Resident Review • (Status Change)

24. OBRA personnel were trained on NEW Resident Review/Status Change in February 2014. Key Points: • OBRAs perform a clinical review of the individual based on information received by the NF. • An OBRA review uses clinical judgment, and any combination of signs/symptoms to assess a case. • Doubling of antidepressant is no longer a trigger . • Psychiatric Hospitalizations have been added. • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

25. Diagnosis of Mental Illness • New Diagnosis: anxiety, personality disorder, panic disorder and somatoform need to be considered through the same clinical lens. • OBRAs job is to substantiate any changes. • SNF job is to reconcile any differences in the medical record using information from OBRA. • Inconsistency between medical record and Level I • Requirement that information on Level I is current & accurate • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

26. Diagnosis of Organic Condition • Old SC form did not consider Organic Conditions • New form provides opportunity to clarify organic conditions that impact a persons presentation Psychotropic Medications • Monitoring medication is important to assessing extenuating circumstances that could be impacting the persons presentation and behaviors • Pay attention to the dosages of medications • Be sure to use diagnoses and not just list symptoms of diagnosis • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

27. OBRA OUTCOMES Determination of the outcome depends on OBRAs findings. Approved, NO MMI No more action is required Approved with follow up next quarter Burdon to follow up is on Nursing Facility Status Change, Approved MMI Previous Level II completed and NO-NEW level II at this time • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

28. OBRA OUTCOMES continued: Refer for Level II MMI transition to primary diagnosis of dementia NEW MMI Substantial change from previous Level II Substantial deterioration in level of functioning NOT due to organic or physical/medical condition Determination of the outcome depends on OBRAs findings. Approved, NO MMI No more action is required Approved with follow up next quarter Burdon to follow up is on Nursing Facility Status Change, Approved MMI Previous Level II completed and NO-NEW level II at this time • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

29. Determinations of outcome depends on OBRA findings: • Approved, NO MMI NO MORE ACTION REQUIRED • Approved with follow up next quarter Burdon to follow up is on Nursing Facility • Status Change, Approved MMI • Previous Level II No New LEVEL II required at this time • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

30. Resident Review- OBRA indication of noncompliance • Status Change • Failure of SNF to refer for status change within 14 days • Failure of SNF to provide necessary information (timely) • Pre-Admission Screen (PAS) • Original PAS does not indicate triggers, where clearly noted • Person admitted without PAS • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

31. OBRA review completion • OBRA will send the signed and completed NEW Resident Review/Status Change form to the Nursing Facility to maintain in the record. • OBRA will keep a copy for the Mental Health Center’s PASRR – OBRA office. • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

32. Severe Anxiety – • Added to list of triggers in early 2014 • If diagnosis captured and screened on PAS, no need for review • If not captured on PAS, needs reviewed for severity & need for treatment. • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

33. Determining Severity of Anxiety – • Level I -completers are required to identify “suspicion” of mental illness. • Level 1.5 -Masspro evaluator determined seriousness and whether Level II required) • Level II -Evaluates severity, impact on functioning and treatment recommendations. • PASRR -Diagnosis and Triggers • Overview OBRA TRAINING (02/2014)

34. PASRR Resident Review/Status Change OBRA review will determine OUTCOME • SEPs – If OBRA indicates COMPLIANCE the date used • for PASRR approval is the date of the original Level I If non-compliance is indicated the EFFECTIVE DATE OBRA fills in is the date of PASRR approval OBRA MUST SIGN

35. PASRR Resident Review/Status Change

37. Survey is the Regulatory Arm of PASRR • OIG requirements for CMS oversight • Colorado Survey Authority = DPHE (public health) • Survey process relies on evidence • Evidence of PAS • Evidence of RR for suspicion of change (MDS) • Evidence of Specialized Service • SURVEY

38. Record Keeping Documentation “There should be no information in the individual’s record to suggest that their condition has changed markedly – for better or worse – since the last evaluation was conducted” • SURVEY-EVIDENCE

39. DPHE – has been notified of upcoming change • DPHE has worked with PASRR ops on the changes • Trained on what to look for regarding PASRR After October 01, 2014 facilities might be cited regarding these changes • SURVEY-Form Simplification

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41. The current approved Level I (PAS) is the online COPASRR.com • Nursing homes cannot complete or accept an old paper Level I PAS • New Level I review update addresses NEW diagnosis • Nursing Home bears final responsibility for Level I accuracy • “Emergency” admits are not exempted from preadmission screening (emergency means immediate placement for life safety) • The OIG recognizes Hospital discharge planners and NF conduct PAS • Parties need to cooperate at the local community level to achieve smooth PAS process • Readmissions within 30days are only subject to a Resident Review • Level I update is appropriate for completion • PASRR- Level I PAS/RR • Questions and Answers session • Colorado PASRR FACTS

42. Nursing Facility placement can be changed in the ONLINE system by referring Site Admin within 72 hours of FINAL approved outcome • NF can complete a Level I update if designated facility changes • Hospital Exemption, only true exemption according to PTAC • Time Limited categories are not exemptions • HCBS respite DOES NOT REQUIRE PASRR (not a NF admission) • PACE RESPITE to LTC requires contacting OBRA for RR if applicable • HCBS respite to LTC requires Level I completion by SEP • New RR/SC replaces Depression Diversion • Level II evaluations need to be sent to Masspro • PASRR- Level I PAS/RR • Questions and Answers session • Colorado PASRR FACTS

43. PASRR Resident Review: The state must periodically review the MI/ID status of NF residents. • Resident Reviews/Status Change must be referred when there is a change or suspected change as indicated by post level I update • SEPs may require NF to contact OBRA for RR prior to approval • Resident Reviews/Status Change must be completed by a state approved reviewer (Colorado OBRA or OBRA coordinator/SIDA) • Nursing facility to Nursing facility transfer need only a Resident Review (including Level II) • Transfer (initial Level I, RR, Level II and determination letter) • PTAC says the goal is to error on the side of positives • PASRR- Level I PAS/RR • Questions and Answers session • Colorado PASRR FACTS

44. Is there a time frame for NF to review PASRR? • Yes, time frame is between July 01 and October 31, 2014 • What should SEPs do if there is a discrepancy? • SEPs should refer NF to OBRA and follow RR/SC form • Is a new Level I needed if meds change before discharge. • A Level I update after admission is appropriate in this case. OBRA will need to be contacted only if indicated by Reason for Update • Notify state Medicaid Agency if there is a recurrent issue. • Does a follow up next quarter outcome require RR/SC • Yes- follow up next quarter is a time limited approval • Who completes the Level I- online {Colorado Rule} • SEPs/Medicaid – Hospitals/Not Medicaid – NF/Pay source  8.401.184 • Frequently Asked Questions

45. Level I flowchart PTAC excerpts Level I process FLOWCHART

46. Level II flowchart PTAC .

47. Resident Review flowchart PTAC .

48. Quality Monitoring in PASRR is coming… • Improves outcomes for individuals Placement options and review of services for Level II • Supports effective and efficient process Identifies non-compliance or needed improvement • Likely to follow NF(QIS) and HCBS(QIS) • Some states already using MDS data to shape their monitoring program and required reporting • PASRR DISCUSSION • Quality Monitoring

49. Quality Monitoring in PASRR–Data elements • Informative Examples • Level I – Number of completed Level I • Level I -- # and percent of positives • Level II -- # and percent of positives that result in Level II • Level II -- # and percent of positive Level II • Resident Review – Number of Resident Reviews • Average length of time in days to complete reviews • Number and percent of PASRR placements in the community • PASRR DISCUSSION • Quality Monitoring

50. AUDIENCE ASK QUESTIONS • PASRR- Level I PAS/RR • Questions and Answers session