PURPOSE: This rule outlines the preadmission screening requirements related to eligibility for Title XIX. PUBLISHER’S NOTE: The publication of the full text of the material that the adopting agency has incorporated by reference in this rule would be unduly cumbersome or expensive. Therefore, the full text of that material will be made available to any interested person at both the Office of the Secretary of State and the office of the adopting agency, pursuant to section 536.031.4, RSMo. Such material will be provided at the cost established by state law.

1. (1) An individual who is admitted to a Medicaid certified bed on or after January 1, 1989, and has not been screened for mental illness and mental retardation prior to admission to a Medicaid-certified nursing facility

2. (NF) bed or who does not have a valid special admission exemption will not be eligible for Title XIX payments to be made on his/her behalf for NF services.

   1. (A) This rule incorporates by reference 42 Code of Federal Regulations (CFR) 483.20(m)(1) and (2).
   2. (B) For purposes of this rule an individual is considered to have mental illness if the individual has a serious mental illness as defined in 42 CFR 483.102(b)(1) which is hereby incorporated by reference.
   3. (C) For purposes of this rule an individual is considered to be mentally retarded if the individual is mentally retarded as defined in 42 CFR 483.102(b)(3), which is hereby incorporated by reference, or is a person with a related condition as described in 42 CFR 435.1009, which is hereby incorporated by reference.
3. (2) The requirement for preadmission screening applies whether the individual is a Medicare beneficiary, Medicaid recipient or private pay.

4. (3) Preadmission screening and resident reviews (PASARR) will include an assessment of the individual’s:

   1. (A) Physical condition;
   2. (B) Mental condition; and
   3. (C) Need for specialized services for mental illness or mental retardation.

5. (4) For purposes of this rule, the term “specialized services” is defined for individuals with—

   1. (A) Mental illness as the implementation of an individualized plan of care developed under and supervised by a physician, provided by a physician and other qualified mental health professionals, that prescribes specific therapies and activities for the treatment of persons who are experiencing an acute episode of serious mental illness which necessitates supervision by trained mental health personnel; and
   2. (B) Mental retardation or other related condition(s) as a continuous program for each client, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and services that are directed towards the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal function status. Specialized services do not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous treatment program.
6. (5) Medical information needed to do the assessments will be furnished by the attending physician. Other information needed to make the assessments, such as social history and behavior, may be furnished by the individual, guardian, family members, social workers or other persons.

7. (6) The preadmission screening and resident review process will be divided into two (2) parts: Level I and Level II.

   1. (A) The purpose of a Level I screening is to identify a nursing facility applicant or resident who is known or suspected to be mentally ill, mentally retarded or developmentally disabled.
   2. (B) The purpose of a Level II screening is to confirm that the individual is mentally impaired and to determine whether the individual needs specialized services and determine if a nursing facility is an appropriate setting. If a determination is made that placement in an NF is inappropriate, no Title XIX vendor payments will be made or continue to be made in the case of a resident already in the NF.

8. (7) Any individual identified to be or suspected to be mentally ill, mentally retarded or developmentally disabled by the Level I screening may require a Level II screening. A Level II screening must be performed prior to admittance into a certified bed located in an NF, unless a valid special admission category applies.

   1. (A) The Level II screening shall be performed by the Department of Mental Health or its designee. If a review indicates that specialized services are required at a level of care that can only be furnished in an intermediate care facility for the mentally retarded (ICF/MR), within the Home and Community- Based Waiver for the Developmentally Disabled or an acute care mental hospital, that individual is inappropriate for admission or continued stay in an NF. This will be true even if the individual meets the eighteen (18)- point count under 13 CSR 15-9.030 needed for authorization of Medicaid nursing facility payments.

      1. 1. If an individual described in subsec-

tion (7)(A) has medical needs which can only be met in an NF, as confirmed by and recommended by a Level II screening and communicated to the nursing facility by the Division of Aging, that individual may be admitted or continue to remain in an NF. If the medical condition improves and nursing needs could be met in other settings, the individual shall be discharged.

1. 2. Notice of a decision resulting from a

Level II screening shall be sent by the Division of Aging to the referring entity who submitted the Level I screening forms and the proposed placement facility, if different.

1. (B) Any individual suspected of being mentally ill, mentally retarded or developmentally disabled by the Level II process and who has been admitted to an NF shall be subject to a Level II preadmission screening/resident review. Any individual determined through the Level II process to be mentally ill, mentally retarded or developmentally disabled and to require specialized services shall be discharged if a Level II screening determines nursing care needs can be met in other settings regardless of the point count under 13 CSR 15-9.030.

2. (C) Special admission categories are as follows:

   1. 1. A person who qualifies for a special

admission category shall have mental health screen performed as detailed per the following:

1. A. Terminal illness. The person is

certified by a physician to be terminally ill. As defined by the Social Security Act an individual is considered to be terminally ill if there is a medical prognosis that the individual’s life expectancy is six (6) months or less; and

1. B. Severely ill. The person is

comatose, ventilator dependent, functions at brain stem level or has a diagnosis of chronic obstructive pulmonary disease, severe Parkinson’s disease, Huntington’s disease, Amyotrophic Lateral Sclerosis or congestive heart failure which results in a level of physical impairment so severe the individual could not be expected to benefit from specialized services; and

1. 2. The following special admission cate-

gories may require a mental health evaluation following admission:

1. A. Direct transfer from a hospital—If

a physician attests that the individual is likely to need thirty (30) days or less of nursing facility care for the condition for which the individual was hospitalized, no Level II screening is necessary and the individual is exempt from the PASARR process. Nursing facility payment will be made for no more than thirty (30) days. If it becomes apparent that the individual will need longer than thirty (30) days, the facility must immediately notify the Division of Aging. If a continued stay is approved, a Level II screening may be performed;

1. B. Emergency provisional admis-

sion—This category is for a situation in which an individual needs placement to protect the individual from serious physical harm to self or others. The nursing facility must contact the Division of Aging Elderly Abuse/Neglect hotline to make a formal request. This special admission category requires prior authorization by the Division of Aging as an emergency. No more than seven (7) days will be allowed for an emergency admission. The Division of Family Services will manage those dates based on information from the Division of Aging. If the resident needs to stay in the facility longer than seven (7) days, the facility must immediately notify the Division of Aging to determine continued stay. A Level II screening may be performed after the initial seven (7)-day period; and

1. C. Respite care—An individual may

be admitted and remain in a facility for thirty (30) consecutive days or less with a forty-two (42)-day maximum in twelve (12) months in order to provide respite for the individual’s caregiver. A Level II screening is not required. The Division of Family Services will control the nursing facility authorized payment dates by means of a form they send to the state office. No payment will be made to the nursing facility beyond the thirty (30) days. If a situation arises in which the stay is longer than thirty (30) days, the nursing facility must contact the Division of Aging. If a continued stay is authorized, a Level II screening may be performed.

1. (8) The Department of Social Services and the Department of Mental Health will have joint responsibility for the preadmission screening process.

AUTHORITY: sections 208.153, and 208.201, RSMo 1994.* Emergency rule filed Dec. 30, 1988, effective Jan. 10, 1989, expired April 29, 1989. Original rule filed Feb. 15, 1989, effective April 27, 1989. Amended: Filed June 6, 1989, effective Aug. 24, 1989. Amended: Filed July 23, 1991, effective Dec. 9, 1991. Amended: Filed May 27, 1999, effective Jan. 30, 2000. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991 and 208.201, RSMo 1987.